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{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378302
}
|
The patient has no history of gynecological surgeries or complications.
The patient presented with mild intermittent lower abdominal pain on the left side.
Transvaginal ultrasound revealed a 4 cm simple cyst on the left ovary.
Other ovarian cyst, left side: A simple cyst identified on the left ovary during imaging studies.
The patient's symptoms and ultrasound findings are consistent with a benign ovarian cyst on the left side. No signs of ovarian torsion or other complications observed.
Prescribed ibuprofen for pain management and advised a follow-up ultrasound in 3 months to monitor the cyst's size.
Patient discharged in stable condition with instructions for symptom monitoring and follow-up care.
34
Female
Caucasian
ICD Code: N83292
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378303
}
|
The patient has a history of irregular menstrual cycles but no previous gynecological surgeries or known reproductive disorders.
The patient presented with sudden onset severe right lower abdominal pain, nausea, and vomiting.
Ultrasound showed an enlarged right ovary with free fluid in the pelvis. Doppler study revealed absent blood flow to the right ovary.
Torsion of right ovary and ovarian pedicle. Verbatim EHR quote justifying the code: 'Patient diagnosed with torsion of right ovary and ovarian pedicle confirmed by ultrasound and Doppler study.'
Physical examination revealed tenderness in the right lower abdomen with guarding. Urgent surgical consultation was sought due to suspicion of ovarian torsion.
The patient underwent emergency laparoscopic detorsion of the right ovary with good perfusion noted post-procedure. Intravenous fluids and analgesics were administered.
The patient recovered well post-operatively with resolution of symptoms. Discharged home with instructions for follow-up with the gynecologist in two weeks.
32
Female
Caucasian
ICD Code: N83511
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378304
}
|
The patient has a history of irregular menstrual cycles but no prior history of ovarian cysts or torsion.
The patient presented with sudden onset severe left lower abdominal pain, nausea, and vomiting.
Ultrasound showed a left ovarian mass with whirlpool sign, indicating torsion. Doppler study revealed decreased blood flow to the left ovary.
Torsion of left ovary and ovarian pedicle. The left ovary is twisted on its pedicle, compromising blood flow and causing severe pain. This is a surgical emergency that requires immediate intervention to salvage the ovary.
The patient's physical exam was significant for left lower abdominal tenderness with guarding. Imaging studies confirmed the diagnosis of left ovarian torsion.
Emergency laparoscopic detorsion was performed successfully, restoring blood flow to the left ovary. The ovary appeared viable post-procedure.
The patient recovered well post-operatively and was discharged with instructions for close follow-up to monitor ovarian function and prevent future torsion events.
32
Female
Caucasian
ICD Code: N83512
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378305
}
|
The patient has a history of irregular menstrual cycles but no prior history of ovarian cysts, torsion, or other gynecological disorders.
The patient presents with mild pelvic discomfort and irregular menstrual bleeding. She denies any acute abdominal pain, fever, or abnormal vaginal discharge.
Transvaginal ultrasound shows a 4 cm simple cyst on the right ovary. CA-125 levels are within normal limits.
Other noninflammatory disorders of ovary, fallopian tube and broad ligament (N838): The patient presents with a simple ovarian cyst on the right ovary without signs of torsion or inflammation.
The patient's symptoms and imaging findings are consistent with a simple ovarian cyst, and there is no evidence of torsion or inflammatory changes.
The patient was counseled on watchful waiting and advised to follow up if symptoms worsen. No surgical intervention is currently indicated.
The patient was discharged home with instructions for symptom monitoring and a follow-up appointment in two months.
34
Female
Caucasian
ICD Code: N838
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378306
}
|
The patient has a history of irregular menstrual cycles but no history of ovarian cysts, torsion, polyps, or other uterine disorders.
The patient presents with lower abdominal pain and bloating, along with irregular menstrual bleeding.
Ultrasound shows no evidence of ovarian cysts or torsion. Blood tests indicate normal hormone levels.
Noninflammatory disorder of ovary, fallopian tube and broad ligament, unspecified. The patient presents with lower abdominal pain, bloating, and irregular menstrual bleeding. Ultrasound ruled out ovarian cysts or torsion. Hormone levels are within normal limits.
The patient reports cyclic lower abdominal pain and bloating, consistent with the diagnosis of a noninflammatory disorder of the ovary, fallopian tube, and broad ligament. No palpable masses or tenderness on pelvic exam.
Prescribed pain management for abdominal discomfort and advised to follow up if symptoms persist or worsen.
The patient's symptoms improved with treatment, and she was discharged with instructions for follow-up if needed.
34
Female
Caucasian
ICD Code: N839
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378307
}
|
The patient has a history of irregular menstrual cycles and postmenopausal bleeding.
The patient presented with postmenopausal bleeding and occasional pelvic pain.
Endometrial biopsy revealed atypical glandular cells consistent with Endometrial intraepithelial neoplasia (EIN).
Endometrial intraepithelial neoplasia (EIN) is a premalignant condition characterized by the proliferation of atypical endometrial glandular cells. The diagnosis is confirmed by histopathological examination of endometrial tissue obtained through biopsy.
The patient's endometrial biopsy results indicate the presence of atypical glandular cells consistent with Endometrial intraepithelial neoplasia (EIN). Further evaluation for treatment planning is recommended.
The patient is scheduled for a hysteroscopic resection of the abnormal endometrial tissue. Hormone therapy will be considered postoperatively.
The patient underwent a successful hysteroscopic resection of the Endometrial intraepithelial neoplasia (EIN) lesion without complications. She is advised to follow up for further treatment planning and monitoring.
58
Female
Caucasian
ICD Code: N8502
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378308
}
|
The patient has a history of malposition of the uterus, which has been previously documented in medical records.
The patient presents with symptoms of lower abdominal pain, abnormal uterine bleeding, and dyspareunia, all of which are indicative of malposition of the uterus.
Transvaginal ultrasound shows the malposition of the uterus, with the fundus deviated from its normal position.
Malposition of uterus as documented in the medical records: 'Malposition of uterus.'
Upon examination, the physician palpated the uterus and noted the malposition, which was further confirmed by imaging studies.
The patient has been prescribed a course of physical therapy to help reposition the uterus. Additionally, NSAIDs have been recommended for pain management.
The patient responded well to treatment and was discharged with instructions for follow-up visits to monitor the repositioning of the uterus.
35
Female
Caucasian
ICD Code: N854
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378309
}
|
The patient has a history of irregular menstrual cycles and pelvic pain.
The patient presents with severe lower abdominal pain, bloating, and vaginal bleeding.
Transvaginal ultrasound shows a distended uterus with blood clots consistent with hematometra.
Hematometra. The ultrasound revealed a distended uterus with blood clots, confirming the diagnosis of Hematometra.
Upon examination, the patient showed tenderness in the lower abdomen. The ultrasound findings are indicative of Hematometra.
The patient was started on nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management and scheduled for a dilation and curettage (D&C) procedure.
The patient responded well to treatment and was discharged with instructions for follow-up care post-D&C.
38
Female
Caucasian
ICD Code: N857
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378310
}
|
The patient has a history of irregular menstrual cycles and pelvic pain.
The patient presents with abnormal uterine bleeding, pelvic discomfort, and dyspareunia.
Transvaginal ultrasound shows the presence of a uterine fibroid.
Other specified noninflammatory disorders of uterus (N858): The uterus fibroid is causing abnormal uterine bleeding and pelvic pain.
The patient reports worsening symptoms during menstruation, consistent with the presence of a uterine fibroid.
Prescribed NSAIDs for pain management and referred the patient to a gynecologist for further evaluation and management of the uterine fibroid.
The patient was discharged in stable condition with instructions to follow up with the gynecologist for treatment of the uterine fibroid.
38
Female
Caucasian
ICD Code: N858
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378311
}
|
The patient has a history of regular gynecological check-ups with no significant findings related to the uterus or ovaries.
The patient reports mild pelvic discomfort and abnormal uterine bleeding.
Transvaginal ultrasound shows a normal-sized uterus with no signs of inflammation or structural abnormalities.
Noninflammatory disorder of uterus, unspecified (N859): The term 'noninflammatory' in this context indicates the absence of inflammation in the uterus, aligning with the patient's presentation of mild symptoms and normal ultrasound findings.
The patient's symptoms and diagnostic results are consistent with a noninflammatory disorder of the uterus. No signs of torsion, polyps, neoplasia, malposition, hematometra, or other specified noninflammatory disorders are observed.
Prescribed oral contraceptives for hormonal regulation and advised to monitor symptoms for any changes.
The patient was discharged in stable condition with instructions for follow-up in case of persistent symptoms or new concerns.
35
Female
Caucasian
ICD Code: N859
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378312
}
|
The patient has a history of regular gynecological screenings and pap smears.
The patient is asymptomatic and denies any abnormal vaginal bleeding, discharge, or pelvic pain.
Pap smear results indicate atypical squamous cells of undetermined significance (ASCUS) prompting further evaluation.
Dysplasia of cervix uteri, unspecified. Verbatim EHR quote justifying the code: 'Pap smear results indicate atypical squamous cells of undetermined significance (ASCUS) which are consistent with dysplasia of the cervix uteri.'
On pelvic exam, the cervix appears normal without any visible lesions. Colposcopy scheduled for further evaluation.
Colposcopy and possible biopsy to assess the extent of cervical dysplasia. Education provided on the importance of regular follow-ups.
The patient is scheduled for a colposcopy and biopsy. Discharge instructions include follow-up in two weeks for further management.
35
Female
Caucasian
ICD Code: N879
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378313
}
|
The patient has a history of regular gynecological check-ups with no prior abnormalities reported.
The patient presented with abnormal vaginal bleeding between menstrual cycles and postcoital bleeding.
Transvaginal ultrasound showed no structural abnormalities in the uterus or ovaries. Pap smear results were negative for any dysplastic changes.
Other specified noninflammatory disorders of cervix uteri (N888): The cervix uteri appears normal on examination, ruling out dysplasia or structural abnormalities.
The patient denies any history of sexually transmitted infections or pelvic inflammatory disease. Cervical motion tenderness was absent on physical examination.
The patient was reassured about the benign nature of the condition. No specific treatment was initiated, and the patient was advised to monitor symptoms and follow up if bleeding persists.
The patient was discharged in stable condition with instructions for follow-up in case of persistent abnormal vaginal bleeding.
38
Female
Caucasian
ICD Code: N888
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378314
}
|
The patient has a history of irregular menstrual cycles and pelvic pain.
The patient presents with postcoital bleeding and dyspareunia.
Pelvic ultrasound shows no structural abnormalities in the uterus or ovaries.
Other specified noninflammatory disorders of vagina (N898): The patient presents with postcoital bleeding and dyspareunia. Pelvic ultrasound ruled out structural abnormalities in the uterus or ovaries.
The patient reports no history of abnormal pap smears or sexually transmitted infections. Physical examination reveals tenderness upon palpation of the vaginal walls.
Prescribed topical estrogen cream for symptomatic relief. Advised on safe sexual practices and scheduled for a follow-up in 6 weeks.
The patient responded well to treatment and was discharged in stable condition with scheduled follow-up.
35
Female
Caucasian
ICD Code: N898
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378315
}
|
The patient has a history of chronic vulvar irritation and itching.
The patient presents with persistent white patches on the vulvar skin.
Biopsy results confirm the presence of leukoplakia on the vulva.
Leukoplakia of vulva
The patient's symptoms and biopsy results are consistent with leukoplakia of the vulva.
Prescribed topical corticosteroids for symptomatic relief and scheduled for surgical removal of the leukoplakia patches.
The patient was discharged in stable condition with instructions to follow up after the surgical procedure.
45
Female
Caucasian
ICD Code: N904
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378316
}
|
The patient has a history of recurrent vulvar irritation and discomfort.
The patient complains of itching and burning sensation in the vulvar area.
Physical examination revealed erythema and excoriation of the vulvar skin.
Other specified noninflammatory disorders of vulva and perineum
The patient presents with localized vulvar erythema and excoriation without signs of inflammation.
Prescribed topical emollients and advised on vulvar hygiene practices.
Patient discharged in stable condition with instructions for follow-up in two weeks.
42
Female
Caucasian
ICD Code: N9089
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378317
}
|
The patient, a 28-year-old female, has a history of regular menstrual cycles since menarche at age 12.
The patient reports the sudden cessation of menstruation for the past seven months. She experiences occasional hot flashes, breast tenderness, and vaginal dryness.
Pregnancy test results are negative. Thyroid function tests indicate normal levels. Hormone panel reveals low estrogen and progesterone levels.
Secondary amenorrhea (N911): The criteria for secondary amenorrhea are met as the patient, a 28-year-old female, has experienced the absence of menses for seven months, along with symptoms of hormonal imbalance including hot flashes, breast tenderness, and low estrogen and progesterone levels.
Patient presents with classic symptoms of secondary amenorrhea including hot flashes, breast tenderness, and low hormone levels. No signs of pregnancy or thyroid dysfunction noted. Differential diagnosis ruled out primary amenorrhea and menopause.
Treatment plan includes hormone replacement therapy to regulate the menstrual cycle and address hormonal imbalances. Patient advised on lifestyle modifications and follow-up hormone level monitoring.
The patient responded well to hormone replacement therapy and was discharged with instructions for follow-up hormone level checks in three months.
28
Female
Caucasian
ICD Code: N911
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378318
}
|
The patient has a history of irregular menstrual cycles with occasional missed periods in the past year.
The patient reports the absence of menstrual periods for the last six months without other associated symptoms such as hot flashes, vaginal dryness, or excessive bleeding.
Pregnancy test results are negative. Thyroid function tests are within normal limits.
Amenorrhea, unspecified: The patient presents with the absence of menstruation for six months without other specific symptoms or underlying causes.
The patient denies any recent weight changes, stress, or significant lifestyle modifications that could explain the amenorrhea. Physical examination shows no signs of androgen excess or thyroid abnormalities.
The patient will be counseled on the implications of amenorrhea and the potential need for further evaluation if the condition persists.
The patient was discharged with recommendations for follow-up if menstruation does not resume within the next three months.
28
Female
Caucasian
ICD Code: N912
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378319
}
|
The patient has a history of regular menstrual cycles with no previous gynecological abnormalities.
The patient reports experiencing excessive and frequent menstruation with a consistent cycle length of 28 days.
Pelvic ultrasound shows a normal uterine and ovarian structure with no signs of abnormalities.
Excessive and frequent menstruation with regular cycle. The patient presents with menorrhagia and metrorrhagia, consistent with the diagnosis of N920.
The patient denies any intermenstrual bleeding, pelvic pain, or other gynecological symptoms. No signs of hormonal imbalances or structural abnormalities were noted upon examination.
Prescribed oral contraceptives to regulate menstrual flow and advised on lifestyle modifications.
The patient responded well to treatment and was discharged in stable condition with a follow-up scheduled in 3 months.
32
Female
Caucasian
ICD Code: N920
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378320
}
|
The patient has a history of regular gynecological check-ups with no reported abnormalities in previous menstrual cycles.
The patient presents with complaints of irregular menstrual cycles occurring every 21 to 35 days, heavy bleeding lasting more than 7 days, and intermittent spotting between periods.
Transvaginal ultrasound showed no structural abnormalities in the uterus or ovaries. Hormonal blood tests revealed normal levels of estrogen, progesterone, and thyroid hormones.
Excessive and frequent menstruation with irregular cycle (ICD-10-CM code N921) - The patient presents with irregular menstrual cycles every 21 to 35 days, heavy bleeding lasting more than 7 days, and intermittent spotting between periods.
The patient reports irregular menstrual cycles with heavy bleeding and intermittent spotting, consistent with the diagnosis of Excessive and frequent menstruation with irregular cycle (N921). No signs of noninflammatory disorders of the uterus or dysplasia of the cervix were noted during the physical examination.
Treatment includes oral contraceptive pills to regulate the menstrual cycle and reduce the amount of bleeding. The patient was advised to monitor her symptoms and follow up in 3 months.
The patient responded well to treatment with oral contraceptive pills. She was discharged with instructions to continue the medication as prescribed and to follow up with her gynecologist as scheduled.
32 years
Female
Caucasian
ICD Code: N921
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378321
}
|
The patient has a history of irregular menstrual cycles but no prior abnormal bleeding episodes.
The patient presents with prolonged and heavy menstrual bleeding occurring irregularly between cycles, with no intermenstrual bleeding or postcoital bleeding.
Transvaginal ultrasound shows no structural abnormalities in the uterus or ovaries. Coagulation studies are within normal limits.
Other specified abnormal uterine and vaginal bleeding (N938): The patient presents with prolonged and heavy menstrual bleeding occurring irregularly between cycles, ruling out other causes of abnormal bleeding.
The patient denies any history of cervical dysplasia, cervix uteri stricture, or leukoplakia. No signs of amenorrhea, excessive menstruation, dysmenorrhea, or postmenopausal bleeding are present. The patient's symptoms align with a diagnosis of Other specified abnormal uterine and vaginal bleeding (N938).
The patient is advised to monitor menstrual bleeding patterns and consider hormonal therapy to regulate menstrual cycles.
The patient's condition improved with the current treatment plan, and she is advised to follow up if any new symptoms arise.
32
Female
Caucasian
ICD Code: N938
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378322
}
|
The patient has a history of regular menstrual cycles without any significant gynecological issues.
The patient reports recurrent lower abdominal cramping pain that occurs just before and during menstruation. The pain is described as dull and aching, not associated with other gastrointestinal symptoms.
Pelvic ultrasound shows a normal uterus and ovaries without any structural abnormalities. Laboratory tests indicate normal hormone levels.
Dysmenorrhea, unspecified. The patient presents with recurrent lower abdominal pain associated with menstruation. The pain is not due to any other underlying pathology.
The patient's symptoms are classic for primary dysmenorrhea, with no evidence of secondary causes such as endometriosis or fibroids. Physical examination reveals no abnormalities.
Prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief during menstruation. Advised on lifestyle modifications and heat therapy.
The patient responded well to treatment and was discharged with instructions for follow-up if needed.
27
Female
Caucasian
ICD Code: N946
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378323
}
|
The patient has a history of irregular menstrual cycles and pelvic pain.
The patient presents with pelvic pain, abnormal vaginal bleeding, and discomfort during intercourse.
Transvaginal ultrasound shows a thickened endometrial lining.
Other specified conditions associated with female genital organs and menstrual cycle (N9489).
The patient reports recent weight gain and fatigue. Pelvic examination reveals tenderness in the lower abdomen.
Prescribed oral contraceptives to regulate menstrual cycles and scheduled a follow-up appointment for a possible endometrial biopsy.
The patient was discharged in stable condition with instructions to monitor bleeding patterns and follow up as scheduled.
34
Female
Caucasian
ICD Code: N9489
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378324
}
|
The patient has a history of infertility and is undergoing assisted reproductive technology (ART) procedures.
The patient presents with abdominal bloating, nausea, and decreased urine output.
Ultrasound shows enlarged ovaries with multiple follicles, and laboratory tests reveal markedly elevated estradiol levels.
Hyperstimulation of ovaries (N981): Ovarian hyperstimulation syndrome.
The patient is experiencing symptoms consistent with ovarian hyperstimulation, including abdominal discomfort and signs of fluid shift such as decreased urine output. Close monitoring for potential complications like ascites and pleural effusion is crucial.
Treatment includes intravenous fluids, pain management, and close observation. Ovarian stimulation medications have been discontinued.
The patient responded well to treatment and was discharged with instructions for follow-up monitoring of symptoms and estradiol levels.
34
Female
Caucasian
ICD Code: N981
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378325
}
|
The patient underwent a laparoscopic surgery for endometriosis six months ago.
The patient complains of chronic pelvic pain and bloating, aggravated by movement. She reports no abnormal uterine bleeding, postmenopausal bleeding, or dysmenorrhea.
Pelvic ultrasound shows evidence of pelvic peritoneal adhesions with no other significant findings.
Postprocedural pelvic peritoneal adhesions
Upon examination, the patient has tenderness in the lower abdomen with palpable adhesions. There are no signs of abnormal uterine or vaginal bleeding. The patient's symptoms are consistent with postprocedural pelvic peritoneal adhesions.
Prescribed nonsteroidal anti-inflammatory drugs for pain management and referred to a specialist for further evaluation.
The patient was discharged with pain relief medication and advised to follow up with the specialist for ongoing management of postprocedural pelvic peritoneal adhesions.
38
Female
Caucasian
ICD Code: N994
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378326
}
|
The patient has a history of a urinary diversion surgery due to bladder cancer.
The patient presents with redness, warmth, tenderness, and purulent discharge around the incontinent external stoma of the urinary tract.
Urinalysis shows leukocytosis and bacteriuria. Wound culture confirms the presence of Escherichia coli.
Infection of incontinent external stoma of urinary tract (N99521): Infection of incontinent external stoma of urinary tract
Physical examination revealed signs of inflammation around the stoma site. The patient complained of pain and discomfort in the stoma area. Lab results indicate a bacterial infection with Escherichia coli.
The patient was started on a course of oral antibiotics, and the stoma site was cleaned and dressed regularly. Education on stoma care and hygiene was provided.
The patient responded well to treatment, with resolution of symptoms and signs of infection. Discharged with a prescription for a full course of antibiotics and instructions for stoma care at home.
68
Female
Caucasian
ICD Code: N99521
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378327
}
|
The patient has a history of a surgical procedure to create an incontinent external stoma of the urinary tract due to underlying urinary incontinence issues.
The patient presents with leakage of urine around the stoma site, skin irritation, and difficulty in maintaining the stoma appliance.
Physical examination shows redness and excoriation around the stoma without signs of infection. No systemic signs of infection such as fever or elevated white blood cell count are noted.
Malfunction of incontinent external stoma of urinary tract. Verbatim EHR quote justifying the code: 'The patient presents with leakage of urine around the stoma site, skin irritation, and difficulty in maintaining the stoma appliance.'
On examination, the stoma appears to be well-healed without any signs of acute infection. The patient reports no history of recent trauma or surgical procedures that could explain the stoma malfunction.
The patient was advised on proper stoma care techniques, including changing the appliance regularly, ensuring proper fit, and keeping the peristomal skin clean and dry. A referral to a stoma care nurse was made for further assistance.
The patient was discharged in stable condition with instructions on stoma care. Follow-up with the stoma care nurse was scheduled to ensure proper management of the stoma malfunction.
58
Female
Caucasian
ICD Code: N99522
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378328
}
|
The patient has a history of recurrent urinary tract infections and a previous genitourinary system procedure for kidney stone removal.
The patient presents with severe lower abdominal pain, hematuria, and hypotension following a recent genitourinary system procedure.
CT scan shows a hematoma in the bladder and active bleeding in the urethra.
Intraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating a genitourinary system procedure. Verbatim EHR quote justifying the code: 'Patient developed intraoperative hemorrhage and hematoma in the genitourinary system following a recent genitourinary system procedure.'
Patient is hemodynamically unstable and requires urgent intervention to control the bleeding and stabilize the condition.
Immediate surgical exploration and hematoma evacuation, blood transfusion, and broad-spectrum antibiotics for infection prophylaxis.
The patient showed improvement post-operatively, with resolution of symptoms and stable vital signs. Discharged home with close follow-up for wound care and monitoring of renal function.
56
Female
Caucasian
ICD Code: N9961
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378329
}
|
The patient has a history of recurrent urinary tract infections and a previous genitourinary system procedure for kidney stone removal.
The patient presents with acute lower abdominal pain, hematuria, and difficulty urinating following a recent genitourinary system procedure.
Ultrasound shows a laceration in the bladder wall and free fluid in the pelvis.
Accidental puncture and laceration of a genitourinary system organ or structure during a genitourinary system procedure.
The patient's symptoms and diagnostic tests confirm the accidental puncture and laceration of the bladder during the recent genitourinary system procedure.
The patient was treated with antibiotics to prevent infection, and a urinary catheter was inserted to aid in bladder healing.
The patient was discharged in stable condition with instructions for follow-up imaging to monitor bladder healing.
56
Female
Caucasian
ICD Code: N9971
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378330
}
|
The patient has a history of recurrent urinary tract infections and a previous urethral stricture repair surgery.
The patient presented with acute abdominal pain and urinary retention postoperatively.
CT scan showed mild hydronephrosis in the left kidney.
Other intraoperative complications of genitourinary system.
Patient developed acute urinary retention postoperatively, likely due to intraoperative complications during the genitourinary surgery.
Patient was catheterized to relieve urinary retention and started on antibiotics for possible urinary tract infection.
Patient's symptoms resolved with catheterization and antibiotics. Discharged in stable condition with follow-up scheduled in two weeks.
56
Female
Caucasian
ICD Code: N9981
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378331
}
|
The patient has a history of recurrent urinary tract infections and underwent a recent genitourinary procedure.
The patient presents with urinary frequency, urgency, and suprapubic pain post-procedure.
Urinalysis shows pyuria and bacteriuria, suggestive of a urinary tract infection. Renal ultrasound is unremarkable for any obstructive uropathy.
Other postprocedural complications and disorders of genitourinary system (N9989): The patient presents with urinary symptoms and positive urinalysis post-genitourinary procedure, indicating postprocedural complications without evidence of infection, hemorrhage, or accidental injury.
The patient's symptoms are consistent with postprocedural complications following the recent genitourinary procedure. No signs of active infection or hemorrhage are noted. The patient is stable and responding well to treatment.
The patient is started on a course of antibiotics for a presumed urinary tract infection. Symptomatic management with analgesics is initiated for suprapubic pain. Close monitoring of symptoms and repeat urinalysis are planned.
The patient responded well to treatment during the hospital stay. Symptoms improved, and the patient is discharged with a prescription for antibiotics to complete the course. Follow-up with the urology clinic is recommended for further evaluation and monitoring.
56
Female
Caucasian
ICD Code: N9989
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378332
}
|
The patient has a history of ectopic pregnancy.
The patient presents with abdominal pain and vaginal bleeding.
Transvaginal ultrasound shows an ectopic pregnancy located in the right fallopian tube.
Tubal pregnancy without intrauterine pregnancy.
The patient reports sharp right-sided abdominal pain and vaginal bleeding. Ultrasound confirms the presence of an ectopic pregnancy in the right fallopian tube. No intrauterine pregnancy is visualized.
The patient is scheduled for a laparoscopic salpingostomy to remove the ectopic pregnancy and preserve the fallopian tube.
The patient underwent successful laparoscopic surgery to remove the tubal pregnancy. She is stable and will follow up for monitoring of hCG levels to ensure the complete resolution of the ectopic pregnancy.
32
Female
Caucasian
ICD Code: O001
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378333
}
|
The patient has a history of previous spontaneous abortions and no other significant medical history.
The patient presents with lower abdominal pain, vaginal bleeding, and fever following an incomplete spontaneous abortion.
Transvaginal ultrasound shows retained products of conception in the uterus, and blood tests indicate an elevated white blood cell count suggestive of infection.
Genital tract and pelvic infection following incomplete spontaneous abortion. Verbatim EHR quote justifying the code: 'Patient diagnosed with genital tract and pelvic infection following incomplete spontaneous abortion.'
The patient is experiencing signs of infection with localized tenderness on pelvic examination and a foul-smelling vaginal discharge.
The patient was started on intravenous antibiotics to treat the pelvic infection and scheduled for a dilation and curettage (D&C) procedure to remove the retained products of conception.
The patient responded well to treatment, with resolution of symptoms and no signs of ongoing infection upon discharge.
32
Female
Caucasian
ICD Code: O030
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378334
}
|
The patient has a history of incomplete spontaneous abortion.
The patient presents with delayed or excessive hemorrhage following the incomplete spontaneous abortion.
Ultrasound shows products of conception remaining in the uterine cavity, confirming incomplete abortion and the source of hemorrhage.
Delayed or excessive hemorrhage following incomplete spontaneous abortion.
The patient reports heavy bleeding and passing of clots consistent with delayed or excessive hemorrhage post incomplete abortion. Ultrasound confirms retained products of conception as the cause of hemorrhage.
The patient was started on misoprostol to help expel the remaining products of conception and manage the hemorrhage. Close monitoring of vital signs and blood loss was initiated.
The patient responded well to the treatment and her bleeding decreased significantly. She was discharged with instructions for follow-up care and to return if bleeding persists or worsens.
32
Female
Caucasian
ICD Code: O031
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378335
}
|
The patient has a history of pre-term labor in a previous pregnancy.
The patient denies any vaginal bleeding, abdominal pain, or abnormal discharge.
Ultrasound performed shows a singleton intrauterine pregnancy at 22 weeks gestation with no signs of cervical incompetence.
Supervision of pregnancy with history of pre-term labor, second trimester. The patient is currently in her second trimester of pregnancy and has a history of pre-term labor in a previous pregnancy.
Patient is stable and asymptomatic during this visit. No signs of pre-term labor are noted on examination.
Patient advised on the signs of pre-term labor and the importance of regular follow-ups. Prescribed prenatal vitamins and scheduled for a follow-up visit in four weeks.
28
Female
Caucasian
ICD Code: O09212
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378336
}
|
The patient has a history of poor reproductive outcomes and obstetric complications.
The patient is currently asymptomatic and is under routine supervision.
Ultrasound performed at 20 weeks gestation shows a viable intrauterine pregnancy.
Supervision of pregnancy with other poor reproductive or obstetric history, second trimester. The patient has a history of poor reproductive outcomes and obstetric complications. She is currently asymptomatic and is under routine supervision. Ultrasound performed at 20 weeks gestation shows a viable intrauterine pregnancy.
The patient is stable, with regular prenatal visits scheduled every two weeks. She is advised to continue folic acid supplementation and to monitor fetal movements. No signs of complications noted during the current visit.
The patient is not currently on any specific treatment other than routine prenatal vitamins and supplements.
31
Female
Caucasian
ICD Code: O09292
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378337
}
|
The patient is an elderly primigravida with no significant past medical history.
The patient reports typical third-trimester pregnancy symptoms such as fetal movements, back pain, and mild swelling.
Ultrasound shows a single live intrauterine pregnancy consistent with the third trimester.
Supervision of elderly primigravida, third trimester. Verbatim_EHR_quote_justifying_the_code: 'Supervision of elderly primigravida, third trimester.'
Routine antenatal visit for a healthy elderly primigravida in the third trimester. Fetal heart rate normal. No complaints or complications reported.
Prescribed prenatal vitamins and advised on fetal movement monitoring. Scheduled follow-up in two weeks.
Patient discharged in stable condition with instructions to continue prenatal care and monitor fetal movements regularly.
42
Female
Caucasian
ICD Code: O09513
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378338
}
|
The patient is a 35-year-old female with a history of two previous uncomplicated pregnancies resulting in live births.
The patient is currently asymptomatic and denies any abdominal pain, vaginal bleeding, or unusual discharge.
Ultrasound performed at 8 weeks gestation confirms a single viable intrauterine pregnancy consistent with the first trimester.
Supervision of elderly multigravida, first trimester. Verbatim EHR quote justifying the code: 'The patient, a 35-year-old female with a history of two previous uncomplicated pregnancies resulting in live births, is currently asymptomatic and presents with a single viable intrauterine pregnancy at 8 weeks gestation.'
The patient is in good health with stable vital signs. No concerning findings on physical examination. Counseling provided regarding prenatal care, folic acid supplementation, and upcoming antenatal appointments.
Prescribed prenatal vitamins and scheduled follow-up visit in 4 weeks for routine antenatal care.
35
Female
Not specified
ICD Code: O09521
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378339
}
|
The patient has a history of multiple pregnancies and is currently in the second trimester of the current pregnancy.
The patient reports mild nausea and occasional back pain, which are common in the second trimester of pregnancy. No abnormal symptoms such as vaginal bleeding or severe abdominal pain are present.
Ultrasound performed last week showed a healthy fetus with appropriate growth for gestational age. Maternal blood tests indicate normal levels of hemoglobin and no signs of infection.
Supervision of elderly multigravida, second trimester. Verbatim EHR quote justifying the code: 'Patient is an elderly multigravida in her second trimester of pregnancy requiring routine prenatal care and monitoring.'
The physician notes that the patient's pregnancy is progressing well without any complications. The patient is advised to continue taking prenatal vitamins and to schedule regular follow-up visits.
The patient is prescribed iron supplements to prevent anemia and is counseled on proper nutrition during pregnancy. Routine prenatal care and monitoring are recommended.
The patient is discharged in stable condition with instructions to follow up with her obstetrician in two weeks for a routine prenatal visit.
39
Female
Caucasian
ICD Code: O09522
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378340
}
|
The patient has a history of infertility and is currently undergoing assisted reproductive technology treatments.
The patient is asymptomatic and denies any vaginal bleeding, abdominal pain, or abnormal discharge.
Ultrasound shows a single viable intrauterine pregnancy consistent with the first trimester.
Supervision of pregnancy resulting from assisted reproductive technology, first trimester. Verbatim EHR quote justifying the code: 'Patient undergoing assisted reproductive technology treatments, currently in the first trimester of pregnancy.'
Patient is stable and shows no signs of complications. Continuing with prenatal vitamins and scheduled follow-ups.
Prescribed prenatal vitamins and advised on a healthy lifestyle during pregnancy.
34
Female
Caucasian
ICD Code: O09811
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378341
}
|
The patient has a history of pre-existing essential hypertension before pregnancy, which has been managed with antihypertensive medications.
The patient presents with elevated blood pressure readings consistent with pre-existing essential hypertension, without signs of pre-eclampsia or gestational hypertension. She denies any history of bleeding, abdominal pain, or visual disturbances.
Blood pressure readings consistently show values above normal limits for the patient's age and gestational stage, indicating poorly controlled hypertension. Urinalysis is negative for significant proteinuria.
Pre-existing essential hypertension complicating pregnancy, third trimester. The patient's blood pressure readings are consistently elevated, indicating poorly controlled pre-existing essential hypertension during the third trimester of pregnancy.
The patient's hypertension poses a risk of complications during pregnancy and requires close monitoring to prevent adverse outcomes for both the mother and the fetus. There are no signs of pre-eclampsia or gestational hypertension present.
Treatment includes optimizing antihypertensive medications to achieve better blood pressure control. The patient is advised on lifestyle modifications to help manage her hypertension. Close follow-up appointments are scheduled to monitor blood pressure and adjust medications as needed.
The patient is stable, and her blood pressure is within acceptable limits at discharge. She is instructed to continue her medications, monitor her blood pressure at home, and follow up with her obstetrician regularly for further management of her pre-existing essential hypertension throughout the remainder of her pregnancy.
32
Female
Caucasian
ICD Code: O10013
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378342
}
|
The patient has a history of chronic hypertension predating the current pregnancy.
The patient is asymptomatic for pre-eclampsia, gestational hypertension, or other hypertensive disorders specific to pregnancy.
Blood pressure readings consistently show elevated values above the normal range for the patient's age and gestational stage.
Unspecified pre-existing hypertension complicating pregnancy, second trimester. The patient has chronic hypertension predating the current pregnancy, which is now complicating the ongoing pregnancy.
The patient's blood pressure has been stable but consistently elevated during prenatal visits. No proteinuria, edema, or other signs of pre-eclampsia are present.
The patient is advised on lifestyle modifications to manage hypertension and is prescribed a low-dose antihypertensive medication to control blood pressure during pregnancy.
32
Female
Caucasian
ICD Code: O10912
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378343
}
|
The patient has a history of chronic hypertension predating the current pregnancy.
The patient presents with elevated blood pressure readings during the third trimester of pregnancy.
Lab tests show consistently high blood pressure measurements above 140/90 mmHg.
Unspecified pre-existing hypertension complicating pregnancy, third trimester. The patient has chronic hypertension predating the current pregnancy, which is now complicating the third trimester of pregnancy.
The patient's blood pressure has been consistently elevated during the third trimester, indicating a worsening of the pre-existing hypertension. No signs of pre-eclampsia or other hypertensive disorders specific to pregnancy are present.
The patient is advised to continue monitoring blood pressure regularly and maintain a low-sodium diet. Antihypertensive medication may be initiated if blood pressure remains elevated.
32
Female
Caucasian
ICD Code: O10913
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378344
}
|
The patient has a history of pre-existing hypertension and was diagnosed with pre-eclampsia during the current pregnancy.
The patient presents with high blood pressure, proteinuria, and edema, which are indicative of pre-eclampsia.
Laboratory tests show elevated liver enzymes and low platelet count, consistent with pre-eclampsia.
Pre-existing hypertension with pre-eclampsia, complicating childbirth. The patient presents with high blood pressure, proteinuria, and edema, along with elevated liver enzymes and low platelet count, confirming the diagnosis of pre-eclampsia.
The patient's condition requires close monitoring due to the risks associated with pre-eclampsia during childbirth.
The patient is being closely monitored, and antihypertensive medications are administered to manage blood pressure. In case of severe symptoms, prompt delivery may be necessary to prevent complications.
The patient delivered a healthy baby without significant complications related to pre-eclampsia. Both mother and baby are stable at discharge.
32
Female
Caucasian
ICD Code: O114
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378345
}
|
The patient has a history of uncomplicated pregnancies with normal blood pressure readings.
The patient presents with elevated blood pressure readings during the third trimester without significant proteinuria.
Urinalysis shows no significant proteinuria, and blood tests indicate normal kidney function.
Gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester. The patient presents with elevated blood pressure readings during the third trimester without significant proteinuria.
Patient's blood pressure has been consistently elevated during the third trimester without any signs of pre-eclampsia. No proteinuria detected in multiple urine tests.
Prescribed close monitoring of blood pressure, advised on lifestyle modifications, and scheduled regular follow-up appointments.
The patient was discharged in stable condition with instructions to monitor blood pressure at home and return for regular prenatal check-ups.
29
Female
Caucasian
ICD Code: O133
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378346
}
|
The patient has a history of gestational hypertension without significant proteinuria during the current pregnancy.
The patient presents with elevated blood pressure readings without significant proteinuria.
Urinalysis shows no significant proteinuria.
Gestational [pregnancy-induced] hypertension without significant proteinuria, complicating the puerperium. Verbatim: 'Gestational [pregnancy-induced] hypertension without significant proteinuria complicating the puerperium.'
Patient's blood pressure has been consistently elevated without signs of pre-eclampsia or significant proteinuria. No other complications noted.
Management includes close monitoring of blood pressure, dietary recommendations, and possible antihypertensive medication.
Patient discharged in stable condition with controlled blood pressure. Advised to follow up with the obstetrician for further monitoring post-discharge.
32
Female
Caucasian
ICD Code: O135
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378347
}
|
The patient has a history of uneventful pregnancies in the past.
The patient presents with elevated blood pressure, mild edema in the lower extremities, and proteinuria.
Lab results show elevated blood pressure (140/90 mmHg), proteinuria (300 mg in a 24-hour urine collection), and normal liver and kidney function tests.
Mild to moderate pre-eclampsia, third trimester. Verbatim EHR quote justifying the code: 'The patient presents in the third trimester with elevated blood pressure (>140/90 mmHg on two occasions at least 4 hours apart after 20 weeks of gestation) and proteinuria (300 mg in a 24-hour urine collection), indicating a diagnosis of mild to moderate pre-eclampsia.'
The patient is stable, with no signs of severe pre-eclampsia or HELLP syndrome. Fetal monitoring shows no signs of distress.
The patient is advised bed rest, increased prenatal visits for monitoring, and close blood pressure monitoring. Low-dose aspirin is prescribed for prophylaxis.
The patient responded well to treatment and was discharged with instructions for close follow-up.
32
Female
Caucasian
ICD Code: O1403
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378348
}
|
The patient has a history of uncomplicated pregnancies in the past.
The patient presents with severe hypertension, proteinuria, severe headaches, visual disturbances, and epigastric pain.
Laboratory results show elevated liver enzymes, thrombocytopenia, and proteinuria.
Severe pre-eclampsia, third trimester. The patient presents with severe hypertension, proteinuria, severe headaches, visual disturbances, and epigastric pain.
Patient requires close monitoring due to the severity of symptoms and the risk of complications.
The patient is being treated with antihypertensive medication to control blood pressure and prevent seizures.
The patient's condition improved with treatment, and she was discharged home with instructions for close follow-up care.
32
Female
Caucasian
ICD Code: O1413
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378349
}
|
The patient has a history of normotensive pregnancies with no prior hypertensive disorders. No history of renal disease, diabetes, or chronic hypertension.
The patient presents with severe hypertension (systolic blood pressure 170 mmHg, diastolic blood pressure 112 mmHg), significant proteinuria (7g in 24 hours), epigastric pain, and visual disturbances.
Laboratory tests show elevated liver enzymes (AST 80 U/L, ALT 70 U/L), creatinine level of 1.2 mg/dL, and thrombocytopenia (platelet count 120,000/µL).
Severe pre-eclampsia complicating childbirth. The patient presents with severe hypertension (systolic blood pressure ≥160 mmHg, diastolic blood pressure ≥110 mmHg), significant proteinuria (≥5g in 24 hours), elevated liver enzymes, creatinine >1.1 mg/dL, and thrombocytopenia.
The patient is diagnosed with severe pre-eclampsia based on the clinical presentation and diagnostic findings. Immediate delivery is indicated due to the severity of the condition.
The patient is being prepared for an emergency cesarean section to prevent maternal and fetal complications. Magnesium sulfate is initiated for seizure prophylaxis. Blood pressure control with antihypertensive medications is ongoing.
The patient underwent an uneventful cesarean section. Both the mother and the newborn are stable post-delivery. Blood pressure is gradually decreasing, and renal function is improving. The patient is advised to follow up with the obstetrician for further postpartum care.
32 years
Female
Caucasian
ICD Code: O1414
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378350
}
|
The patient has a history of gestational hypertension during the third trimester of pregnancy.
The patient presents with severe headaches, visual disturbances, epigastric pain, and generalized edema.
Laboratory tests show elevated liver enzymes, thrombocytopenia, and proteinuria of 6g in 24 hours.
Severe pre-eclampsia complicating the puerperium. The patient presents with severe hypertension (systolic blood pressure 170 mmHg, diastolic blood pressure 115 mmHg), significant proteinuria (6g in 24 hours), and laboratory findings consistent with HELLP syndrome.
The patient's condition is severe and requires close monitoring due to the risk of seizures and multi-organ dysfunction.
The patient is being treated with antihypertensive medications to control blood pressure and magnesium sulfate for seizure prophylaxis.
The patient's condition improved with treatment, and blood pressure stabilized. She was discharged with close follow-up for ongoing monitoring of blood pressure and renal function.
32
Female
Caucasian
ICD Code: O1415
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378351
}
|
The patient has a history of gestational hypertension during the third trimester of pregnancy.
The patient presents with epigastric pain, nausea, vomiting, malaise, and edema in the lower extremities.
Laboratory tests show evidence of hemolysis, elevated liver enzymes, and low platelet count.
HELLP syndrome complicating childbirth. Verbatim_EHR_quote_justifying_the_code: 'Diagnosis of HELLP syndrome made based on the presence of hemolysis, elevated liver enzymes, and low platelet count in the absence of significant proteinuria.'
Patient is stable but requires close monitoring due to the severity of HELLP syndrome.
The patient is being treated with magnesium sulfate for seizure prophylaxis and is being prepared for an emergency cesarean section.
The patient underwent an uncomplicated cesarean section and delivered a healthy baby. Mother and baby are stable at discharge.
32
Female
Caucasian
ICD Code: O1424
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378352
}
|
The patient has an unremarkable medical history with regular prenatal check-ups and an overall healthy pregnancy.
The patient presents with elevated blood pressure (systolic >140 mmHg or diastolic >90 mmHg) and new-onset generalized edema in the third trimester.
Lab results show elevated blood pressure readings consistently during prenatal visits without significant proteinuria. No signs of organ damage or abnormal liver function tests are noted.
Unspecified pre-eclampsia, third trimester. The absence of proteinuria and severe features of pre-eclampsia differentiates this case from other pre-eclampsia codes.
The patient's blood pressure has been elevated without proteinuria, ruling out other forms of pre-eclampsia. Close monitoring for signs of worsening pre-eclampsia is advised.
The patient is recommended bed rest, increased prenatal visits for monitoring, and potential induction of labor if signs of worsening pre-eclampsia develop.
The patient's condition remains stable with close follow-up care post-discharge. No signs of progression to severe pre-eclampsia or eclampsia were observed during the hospital stay.
29
Female
Caucasian
ICD Code: O1493
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378353
}
|
The patient is a 29-year-old G1P0 female with no significant past medical history.
The patient presents with severe and persistent nausea and vomiting, leading to dehydration and electrolyte imbalances. She reports weight loss and ketosis.
Laboratory tests show hypokalemia, metabolic alkalosis, and ketonuria.
Hyperemesis gravidarum with metabolic disturbance.
The patient's condition is consistent with severe hyperemesis gravidarum with significant metabolic disturbances. There are no signs of pre-eclampsia or underlying diabetes.
The patient was admitted for intravenous fluid rehydration, electrolyte replacement, antiemetics, and thiamine supplementation.
The patient's symptoms improved with treatment, and she was discharged home with dietary recommendations and antiemetics for outpatient management.
29
Female
Not specified
ICD Code: O211
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378354
}
|
The patient has a history of recurrent urinary tract infections but has not experienced any infections during the current pregnancy until now.
The patient presents with dysuria, frequency, and suprapubic pain. She denies any fever, chills, or flank pain.
Urinalysis shows significant pyuria and bacteriuria. Urine culture is pending.
Unspecified infection of urinary tract in pregnancy, first trimester. Verbatim EHR quote justifying the code: 'Patient presents with dysuria, frequency, and suprapubic pain. Urinalysis shows significant pyuria and bacteriuria.'
The patient is in her first trimester of pregnancy and is currently asymptomatic apart from the urinary symptoms. She has no history of pre-eclampsia, hypertension, or diabetes.
The patient is started on a course of safe antibiotics for urinary tract infections in pregnancy. She is counseled on the importance of completing the full course of antibiotics.
The patient responded well to treatment and her symptoms resolved. She will follow up for a repeat urine culture to ensure clearance of the infection.
28
Female
Caucasian
ICD Code: O2341
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378355
}
|
The patient has a history of uncomplicated pregnancies and deliveries.
The patient reports mild urinary frequency and urgency without dysuria or suprapubic pain.
Urinalysis shows leukocyte esterase and nitrites positive. Urine culture is pending.
Unspecified infection of urinary tract in pregnancy, second trimester. The patient is currently asymptomatic and has no fever or flank pain.
The patient denies any history of kidney stones or renal issues. No costovertebral angle tenderness on exam.
Prescribed nitrofurantoin for 7 days. Advised increased fluid intake. Follow-up urine culture in 2 weeks.
29
Female
Caucasian
ICD Code: O2342
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378356
}
|
The patient has a history of uncomplicated pregnancy without any significant medical issues.
The patient complains of dysuria, frequency, and urgency. No symptoms of pre-eclampsia, hypertension, hyperemesis gravidarum, or diabetes are present.
Urinalysis shows significant pyuria and bacteriuria. Blood pressure is within normal limits. No proteinuria is detected.
Unspecified infection of urinary tract in pregnancy, third trimester (O2343): The patient presents with dysuria, frequency, and urgency along with significant pyuria and bacteriuria on urinalysis, consistent with a urinary tract infection in the third trimester of pregnancy.
The patient denies any abdominal pain, headaches, visual disturbances, or any other symptoms suggestive of pre-eclampsia. Blood pressure remains stable within normal limits throughout the visit.
Prescribed a 7-day course of amoxicillin for the urinary tract infection. Advised increased fluid intake. Follow-up in one week.
The patient responded well to treatment and was discharged home with instructions to complete the antibiotic course and return for follow-up as scheduled.
29
Female
Caucasian
ICD Code: O2343
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378357
}
|
The patient has a history of recurrent urinary tract infections but no other significant medical history.
The patient presents with dysuria, increased urinary frequency, and suprapubic pain. There are no symptoms of pre-eclampsia, hypertension, hyperemesis gravidarum, or gestational diabetes.
Urinalysis shows pyuria, hematuria, and positive nitrites, consistent with a urinary tract infection. Fetal ultrasound is normal with no signs of growth restriction.
Infection of other part of genital tract in pregnancy, second trimester. Verbatim: 'Patient presents with dysuria, increased urinary frequency, and suprapubic pain. Urinalysis shows pyuria, hematuria, and positive nitrites.'
The patient is afebrile with stable vital signs. No signs of pre-eclampsia or other hypertensive disorders. The patient's fundal height corresponds to the gestational age, ruling out growth restriction.
Prescribed a 7-day course of nitrofurantoin for the urinary tract infection. Advised increased fluid intake. Follow-up in two weeks for reassessment.
The patient responded well to treatment, with resolution of symptoms. Discharged home with instructions to complete the antibiotic course and return for follow-up as scheduled.
28
Female
Caucasian
ICD Code: O23592
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378358
}
|
The patient has a known medical history of type 1 diabetes mellitus before pregnancy.
The patient is experiencing increased blood sugar levels and requires insulin therapy to manage diabetes during pregnancy.
Glycated hemoglobin (HbA1c) levels are elevated, indicating poor blood sugar control.
Pre-existing type 1 diabetes mellitus, in pregnancy, first trimester. The patient has a known history of type 1 diabetes mellitus before pregnancy and requires insulin therapy to manage diabetes during pregnancy.
The patient requires close monitoring of blood sugar levels and fetal growth due to the increased risks associated with pre-existing diabetes during pregnancy.
The patient is advised to continue insulin therapy, adhere to a diabetic diet, and attend regular antenatal check-ups.
N/A
32
Female
Caucasian
ICD Code: O24011
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378359
}
|
The patient has no prior history of diabetes mellitus. She has a history of uncomplicated pregnancies in the past.
The patient reports polyuria, polydipsia, and weight loss. No symptoms of urinary tract infection, liver disorders, or other pregnancy-related conditions are present.
Fasting blood glucose levels consistently above 126 mg/dL and elevated HbA1c levels confirm the diagnosis of gestational diabetes mellitus.
Gestational diabetes mellitus in pregnancy, insulin controlled. The patient requires insulin to manage her blood glucose levels effectively.
The patient has been educated on proper insulin administration techniques and glucose monitoring. She understands the importance of glycemic control during pregnancy.
The patient is started on insulin therapy with regular monitoring of blood glucose levels. A diabetic diet plan and regular exercise routine are also recommended.
The patient responded well to insulin therapy during her hospital stay. She is discharged with a glucometer and instructions for follow-up with the endocrinologist.
32
Female
Caucasian
ICD Code: O24414
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378360
}
|
The patient has no history of diabetes mellitus or other significant medical conditions.
The patient reports increased thirst, frequent urination, and fatigue.
Glucose challenge test results showed elevated blood glucose levels consistent with gestational diabetes mellitus.
Gestational diabetes mellitus in pregnancy, unspecified control (ICD-10-CM code O24419): The patient is a pregnant female with elevated blood glucose levels on the glucose challenge test, indicating gestational diabetes mellitus.
The patient's blood pressure is within normal limits. No signs of infection in the urinary tract or other genital parts. Fetal ultrasound shows no abnormalities.
The patient is advised on dietary modifications and glucose monitoring. Referral to a nutritionist for further management.
The patient responded well to dietary changes and glucose monitoring. She will continue to be monitored throughout the pregnancy for any complications related to gestational diabetes mellitus.
32
Female
Caucasian
ICD Code: O24419
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378361
}
|
The patient has a history of uncomplicated pregnancies and deliveries with no prior liver or biliary tract disorders.
The patient presents with right upper quadrant abdominal pain, nausea, vomiting, and elevated liver enzymes.
Ultrasound shows intrahepatic cholestasis without gallstones. Liver function tests reveal elevated serum bile acids.
Liver and biliary tract disorders in pregnancy, third trimester. The patient presents with right upper quadrant abdominal pain, nausea, vomiting, and elevated liver enzymes. Ultrasound shows intrahepatic cholestasis without gallstones. Liver function tests reveal elevated serum bile acids.
The patient is in her third trimester of pregnancy and is experiencing symptoms consistent with intrahepatic cholestasis of pregnancy. The diagnostic tests support the diagnosis of liver and biliary tract disorders specifically related to pregnancy.
The patient is advised to follow a low-fat diet and is prescribed ursodeoxycholic acid to alleviate symptoms and improve liver function.
The patient responded well to treatment and her symptoms improved. She will continue follow-up care with the obstetrics and gastroenterology departments postpartum.
32
Female
Caucasian
ICD Code: O26613
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378362
}
|
The patient has a history of chronic hypertension but no other significant medical conditions.
The patient presents with edema in the lower extremities, elevated blood pressure, and proteinuria.
Urinalysis shows significant proteinuria, and renal function tests indicate impaired kidney function.
Pregnancy related renal disease, third trimester. Verbatim_EHR_quote_justifying_the_code: 'Patient diagnosed with Pregnancy related renal disease in the third trimester based on symptoms of edema, elevated blood pressure, proteinuria, and abnormal renal function test results.'
The obstetrician confirms the diagnosis of Pregnancy related renal disease and recommends close monitoring of renal function and blood pressure.
The patient is started on antihypertensive medication and advised to follow a low-salt diet. Close fetal monitoring is also recommended.
The patient's condition improved with treatment, and she is scheduled for regular follow-up visits to monitor both maternal and fetal well-being.
32
Female
Caucasian
ICD Code: O26833
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378363
}
|
The patient is a 28-year-old G2P1 female with an unremarkable medical history.
The patient reports mild lower abdominal pressure and occasional lower back pain.
Transvaginal ultrasound shows cervical length of 2.5 cm, consistent with cervical shortening in the second trimester.
Cervical shortening, second trimester. Verbatim EHR quote justifying the code: 'Transvaginal ultrasound reveals a cervical length of 2.5 cm, indicative of cervical shortening in the second trimester.'
Patient's vital signs are stable. No signs of infection or preterm labor. Cervical cerclage discussed with the patient.
Prescribed progesterone supplementation and recommended pelvic rest. Scheduled for cervical cerclage procedure next week.
Patient educated on signs of preterm labor and instructed to follow up in two weeks post-cerclage placement.
28
Female
Not specified
ICD Code: O26872
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378364
}
|
The patient has a history of uncomplicated pregnancies and deliveries. No history of gestational diabetes, liver disorders, renal diseases, cervical shortening, or other specified conditions in the first or third trimesters.
The patient presents with mild edema in the lower extremities, occasional heartburn, and increased fetal movements. No symptoms of gestational diabetes, maternal hypotension syndrome, or liver and biliary tract disorders.
Routine prenatal labs show normal blood glucose levels, liver function tests, and renal function. Fetal ultrasound indicates appropriate growth and amniotic fluid levels for the second trimester.
Other specified pregnancy related conditions, second trimester. The patient presents with mild edema, heartburn, and increased fetal movements, consistent with a normal pregnancy in the second trimester.
Patient is stable, with normal vital signs and appropriate weight gain for gestational age. No signs of complications related to gestational diabetes, liver disorders, renal diseases, or cervical shortening.
Recommendations for lifestyle modifications to manage heartburn. Routine prenatal care and monitoring of fetal movements. Follow-up visit scheduled in four weeks for routine antenatal care.
29
Female
Caucasian
ICD Code: O26892
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378365
}
|
The patient has a history of regular prenatal care visits and a previous uncomplicated singleton pregnancy.
The patient reports typical symptoms of pregnancy such as nausea, fatigue, and fetal movements consistent with a twin pregnancy.
Ultrasound findings confirm a dichorionic/diamniotic twin pregnancy in the second trimester.
Twin pregnancy, dichorionic/diamniotic, second trimester.
Patient is stable and shows no signs of complications related to the twin pregnancy. Regular monitoring and follow-up are advised.
Routine prenatal vitamins and folic acid supplementation. Follow-up ultrasound in four weeks.
The patient was discharged home with instructions for continued prenatal care and monitoring of fetal movements. No acute issues identified during hospital stay.
31
Female
Caucasian
ICD Code: O30042
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378366
}
|
The patient is a 32-year-old female in her third trimester of pregnancy with a history of two previous uncomplicated vaginal deliveries.
The patient is asymptomatic and denies any vaginal bleeding, abdominal pain, or abnormal discharge.
Ultrasound performed at 32 weeks gestation confirms the breech presentation of fetus 2.
Maternal care for breech presentation, fetus 2. The patient is in her third trimester of pregnancy, and ultrasound shows the second fetus in breech presentation.
The patient is well-oriented, with stable vital signs. Fetal heart rate monitoring shows reassuring patterns for both fetuses. The patient is scheduled for a follow-up ultrasound in two weeks to monitor fetal presentation.
The patient received counseling on options for delivery, including the possibility of a trial of labor for the second fetus if conditions permit. A plan for close monitoring until delivery is in place.
32
Female
Not specified
ICD Code: O321XX2
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378367
}
|
The patient has a history of uterine fibroids and has been monitored regularly during the current pregnancy.
The patient reports mild abdominal discomfort and occasional spotting.
Ultrasound imaging shows a 5cm benign tumor in the corpus uteri.
Maternal care for benign tumor of corpus uteri, second trimester. The patient presents with a 5cm benign tumor in the corpus uteri as confirmed by ultrasound imaging.
The patient is stable and shows no signs of complications related to the tumor. Close monitoring is advised to track the tumor's growth throughout the remainder of the pregnancy.
The patient is prescribed pain management medication for the abdominal discomfort and advised on the importance of regular follow-up appointments for monitoring.
The patient is discharged in stable condition with instructions to return for a follow-up ultrasound in four weeks.
34
Female
Caucasian
ICD Code: O3412
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378368
}
|
The patient has a history of uterine fibroids diagnosed during routine prenatal care.
The patient reports mild pelvic discomfort and irregular uterine contractions.
Ultrasound shows a 5 cm fibroid in the corpus uteri.
Maternal care for benign tumor of corpus uteri, third trimester. Verbatim_EHR_quote_justifying_the_code: 'Patient diagnosed with a 5 cm fibroid in the corpus uteri during the third trimester of pregnancy.'
Patient's condition stable, no signs of red degeneration or significant growth of the fibroid.
Prescribed pain management for pelvic discomfort. Regular monitoring of fibroid size and fetal well-being.
Patient discharged in good condition with instructions for follow-up monitoring of fibroid and continued prenatal care.
34
Female
Caucasian
ICD Code: O3413
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378369
}
|
The patient is a 32-year-old female with a history of one previous cesarean section.
The patient is asymptomatic with no complaints related to the current pregnancy.
Ultrasound imaging confirmed the presence of a low transverse scar from the previous cesarean delivery.
Maternal care for low transverse scar from previous cesarean delivery. Verbatim EHR quote justifying the code: 'Ultrasound imaging confirmed the presence of a low transverse scar from the previous cesarean delivery.'
Patient's obstetric history indicates a low transverse incision from the prior cesarean section. No complications or issues related to the scar are observed.
No specific treatment is required at this time. Routine prenatal care and monitoring are recommended.
The patient is stable and discharged home with instructions for regular prenatal visits to monitor the scar and overall pregnancy progress.
32
Female
Not specified
ICD Code: O3421
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378370
}
|
The patient has a history of one previous cesarean delivery.
The patient presents for routine maternal care with no specific complaints related to the scar.
No abnormal findings in routine blood work or ultrasound.
Maternal care for unspecified type scar from previous cesarean delivery. The patient has a history of one previous cesarean delivery.
The patient is in good general health, with no complaints related to the scar. The scar from the previous cesarean delivery appears well-healed with no signs of infection or complications.
Routine prenatal vitamins and advice on scar care provided.
The patient is discharged in good condition with a follow-up scheduled for the next prenatal visit.
32
Female
Caucasian
ICD Code: O34219
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378371
}
|
The patient has a history of previous second-trimester pregnancy losses.
The patient reports painless cervical dilation and shortening in the current pregnancy.
Transvaginal ultrasound shows a shortened cervical length of less than 25mm and cervical funneling.
Maternal care for cervical incompetence, second trimester.
Patient presents with a history of painless cervical dilation and shortening, consistent with cervical incompetence. Ultrasound confirms a shortened cervical length of less than 25mm with cervical funneling, indicative of the diagnosis.
Cervical cerclage procedure performed successfully. Patient advised on activity restriction and regular follow-up visits.
Patient discharged in stable condition post-cervical cerclage with instructions for close monitoring and follow-up visits.
29
Female
Caucasian
ICD Code: O3432
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378372
}
|
The patient has a history of two previous spontaneous second-trimester miscarriages due to cervical incompetence.
The patient reports vaginal pressure and mild lower abdominal cramping.
Transvaginal ultrasound shows a shortened cervical length of 2.5 cm, confirming cervical incompetence.
Maternal care for cervical incompetence, third trimester (O3433).
Patient presents with a history of cervical incompetence and is currently experiencing symptoms consistent with the condition. Diagnostic tests confirm a shortened cervical length, indicating cervical incompetence in the third trimester.
Scheduled for an emergency cerclage to prevent preterm labor. Prescribed progesterone supplementation and advised strict bed rest.
Patient responded well to treatment and cerclage procedure. Discharged home with strict instructions for activity restriction and follow-up appointments.
29
Female
Caucasian
ICD Code: O3433
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378373
}
|
The patient has a history of regular prenatal care visits with no reported complications until the current visit.
The patient reports no abnormal symptoms such as decreased fetal movements, poor fetal growth, malpresentation, or abnormalities of pelvic organs.
Ultrasound performed today showed suspected fetal abnormality and damage, warranting further evaluation.
Maternal care for other (suspected) fetal abnormality and damage, not applicable or unspecified.
Patient presents today with concerns regarding fetal health after an abnormal finding on ultrasound. No other significant maternal or fetal issues noted.
Referral to a maternal-fetal medicine specialist for a detailed fetal assessment and genetic counseling.
The patient was discharged in stable condition with instructions to follow up with the specialist for further management.
29
Female
Caucasian
ICD Code: O358XX0
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378374
}
|
The patient is a 28-year-old G2P1 female with a history of uncomplicated first pregnancy and delivery.
The patient reports mild uterine cramping and decreased fetal movements over the past week.
Ultrasound performed at 22 weeks gestation shows poor fetal growth with an estimated fetal weight below the 10th percentile.
Maternal care for other known or suspected poor fetal growth, second trimester, not applicable or unspecified. Verbatim EHR quote justifying the code: 'Ultrasound at 22 weeks gestation indicates poor fetal growth with an estimated fetal weight below the 10th percentile.'
Patient's fundal height is measuring below the expected range for 22 weeks gestation. No signs of cervical incompetence or abnormalities of pelvic organs noted.
Initiated close monitoring with biweekly ultrasounds to track fetal growth. Recommended increased rest and hydration for the patient.
Patient educated on the importance of fetal movement counting and signs of preterm labor. Scheduled for a follow-up ultrasound in two weeks to reassess fetal growth and well-being.
28
Female
Not specified
ICD Code: O365920
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378375
}
|
The patient has a history of regular prenatal care visits with no significant complications reported during the current pregnancy.
The patient reports decreased fetal movements and fundal height measurements consistent with poor fetal growth.
Ultrasound performed shows poor fetal growth with an estimated fetal weight below the 10th percentile for gestational age.
Maternal care for other known or suspected poor fetal growth, third trimester, not applicable or unspecified. Verbatim EHR quote justifying the code: 'Ultrasound findings indicate poor fetal growth with estimated fetal weight below the 10th percentile for gestational age.'
Patient's fundal height measurements have consistently lagged behind the expected growth curve, raising concerns for poor fetal growth. No other maternal or fetal abnormalities were noted during the physical examination.
The patient is counseled on the importance of close monitoring, kick counts, and potential induction of labor if fetal well-being is further compromised.
The patient is discharged home with instructions for fetal movement monitoring and a follow-up appointment scheduled in one week for a repeat ultrasound assessment of fetal growth.
32
Female
Caucasian
ICD Code: O36.5930
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378376
}
|
The patient is a 32-year-old G3P2 pregnant female with an unremarkable medical history during the current pregnancy.
The patient reports a noticeable decrease in fetal movements over the past 24 hours.
Non-stress test (NST) revealed a reassuring fetal heart rate with no accelerations noted during the monitoring period.
Decreased fetal movements, third trimester, not applicable or unspecified. Verbatim EHR quote justifying the code: 'The patient presents with decreased fetal movements in the third trimester, warranting further evaluation and monitoring.'
Upon examination, the patient expressed concerns about the reduced fetal activity. No other concerning symptoms or complications were noted during the assessment.
The patient was advised to perform daily fetal kick counts and return for a follow-up NST in 48 hours. Maternal reassurance and education provided.
The patient was discharged home with instructions for fetal movement monitoring and to seek immediate medical attention if further decreased movements occur.
32
Female
Not specified
ICD Code: O368130
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378377
}
|
The patient has an unremarkable medical history with no prior complications during the current pregnancy.
The patient reports abdominal distension and discomfort, increased fundal height, and fetal movements perceived as excessive.
Ultrasound shows excessive amniotic fluid volume, consistent with Polyhydramnios.
Polyhydramnios, third trimester. The amniotic fluid index is above the 95th percentile, indicating excessive amniotic fluid.
The patient's condition is stable, with no signs of fetal distress. Regular monitoring is advised to track amniotic fluid levels and ensure fetal well-being.
Recommendation for increased prenatal visits for close monitoring. No specific treatment required unless complications arise.
The patient was discharged in good condition with instructions to follow up with regular prenatal visits for monitoring.
29
Female
Caucasian
ICD Code: O403XX0
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378378
}
|
The patient is a 28-year-old G2P1 female with an uneventful prenatal history up to the current pregnancy.
The patient presents with a fever of 38.5°C, uterine tenderness on palpation, and foul-smelling amniotic fluid.
Laboratory tests reveal maternal leukocytosis with a white blood cell count of 15,000/mm³. Amniocentesis shows signs of infection.
Chorioamnionitis, second trimester, not applicable or unspecified (O411220): Infection of the chorion and amnion during the second trimester without specifying further details.
Patient shows signs of intrauterine infection with maternal fever, uterine tenderness, and abnormal amniotic fluid. Plan for immediate intervention to prevent maternal and fetal complications.
The patient has been started on intravenous antibiotics and is scheduled for an urgent cesarean section to prevent further maternal and fetal complications.
28
Female
Not specified
ICD Code: O411220
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378379
}
|
The patient has a history of regular prenatal check-ups without any complications until the current presentation.
The patient presented with clear amniotic fluid leakage and regular contractions within 24 hours of the rupture. Fetal heart rate is within normal limits.
Ultrasound confirmed the gestational age to be at 34 weeks. Nitrazine paper test was positive for amniotic fluid.
Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, third trimester (ICD-10-CM code O42013): The patient presents with clear amniotic fluid leakage and regular contractions within 24 hours of membrane rupture, confirming preterm labor in the third trimester.
Patient is stable, afebrile, and shows no signs of infection. Fetal monitoring is reassuring with no signs of distress. Plan for close monitoring and possible induction if necessary.
The patient was started on antibiotics to prevent infection and corticosteroids for fetal lung maturation. Continuous fetal monitoring and maternal vital signs monitoring were initiated.
The patient responded well to treatment with resolved leakage and contractions. She was discharged with instructions for close follow-up and signs of preterm labor to watch for at home.
27
Female
Caucasian
ICD Code: O42013
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378380
}
|
The patient has a history of a previous uncomplicated pregnancy.
The patient presented with clear amniotic fluid leakage and regular contractions.
Ultrasound confirmed oligohydramnios and no signs of chorioamnionitis.
Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, third trimester. The patient presents with clear amniotic fluid leakage and regular contractions, with ultrasound confirming oligohydramnios and ruling out chorioamnionitis.
Patient is stable, fetal heart rate within normal limits. No signs of infection. Plan for induction of labor discussed with the patient.
Patient started on antibiotics to prevent infection. Induction of labor scheduled.
Patient discharged in stable condition after successful induction of labor. Close follow-up advised postpartum.
29
Female
Caucasian
ICD Code: O42113
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378381
}
|
The patient is a 28-year-old G3P2 female with an unremarkable medical history during the current pregnancy.
The patient presents with a sudden gush of clear fluid per vagina, consistent with the rupture of membranes. She denies contractions, vaginal bleeding, or fever.
Nitrazine paper test shows alkaline pH, ferning pattern on microscopy, and pooling of amniotic fluid on speculum examination.
Preterm premature rupture of membranes, unspecified as to length of time between rupture and onset of labor, third trimester. Verbatim EHR quote justifying the code: 'Patient presents with a sudden gush of clear fluid per vagina, consistent with rupture of membranes, without the onset of labor in the third trimester.'
The patient is hemodynamically stable, afebrile, and fetal heart rate tracing is reassuring. No signs of infection are noted on examination.
The patient is counseled on the signs of labor and advised to monitor fetal movements. Antenatal corticosteroids are administered for fetal lung maturation, and close follow-up is arranged.
28 years old
Female
Not specified
ICD Code: O42913
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378382
}
|
The patient has a history of two previous cesarean sections.
The patient is asymptomatic and denies vaginal bleeding, abdominal pain, or uterine tenderness.
Ultrasound shows the presence of placenta accreta with abnormal adherence to the uterine wall.
Placenta accreta, third trimester. The ultrasound revealed abnormal adherence of the placenta to the uterine wall, consistent with placenta accreta in the third trimester.
Patient is stable with no signs of active bleeding. Discussed the management plan with the patient and scheduled a cesarean hysterectomy.
Scheduled for a cesarean hysterectomy to manage placenta accreta.
34
Female
Caucasian
ICD Code: O43213
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378383
}
|
The patient has a history of two previous uncomplicated pregnancies without any significant issues.
The patient is asymptomatic and denies any vaginal bleeding, abdominal pain, or uterine contractions.
Ultrasound imaging in the third trimester revealed a completely covering placenta over the internal os without any signs of hemorrhage.
Complete placenta previa NOS without hemorrhage, third trimester. The placenta completely covers the internal os without any associated bleeding.
Patient's vital signs are stable, and there are no signs of active bleeding or contractions. The patient is being closely monitored for any signs of bleeding or labor.
The patient is advised strict bed rest and to avoid any strenuous activities. Antenatal corticosteroids have been administered to promote fetal lung maturation in case of preterm labor.
32
Female
Caucasian
ICD Code: O4403
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378384
}
|
The patient is a 32-year-old G3P2 female with a history of two previous uncomplicated pregnancies.
The patient presented with painless vaginal bleeding in the third trimester.
Ultrasound confirmed the diagnosis of Complete placenta previa with active hemorrhage.
Complete placenta previa with hemorrhage, third trimester. Verbatim EHR quote justifying the code: 'Ultrasound findings are consistent with Complete placenta previa with active hemorrhage in the third trimester.'
Patient stable, fetal heart rate within normal limits, no signs of preterm labor.
Patient admitted for observation, IV fluids, and close monitoring. Antenatal corticosteroids given for fetal lung maturity.
Patient discharged in stable condition with instructions for strict bed rest and follow-up appointments with the obstetrician.
32
Female
Not specified
ICD Code: O4413
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378385
}
|
The patient has a history of two previous uncomplicated pregnancies.
The patient presented with sudden onset of vaginal bleeding, abdominal pain, and decreased fetal movements.
Ultrasound revealed a retroplacental clot consistent with premature separation of placenta.
Premature separation of placenta, unspecified, second trimester. Verbatim EHR quote justifying the code: 'Ultrasound revealed a retroplacental clot consistent with premature separation of placenta.'
Patient stable, no signs of preterm labor. Monitoring for signs of fetal distress.
Patient advised bed rest, close monitoring of fetal movements, and follow-up ultrasound in one week.
Patient discharged in stable condition with instructions to return if bleeding or abdominal pain worsen.
29
Female
Caucasian
ICD Code: O4592
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378386
}
|
The patient is a 32-year-old G2P1 female with an unremarkable medical history regarding pregnancies.
The patient presented with sudden onset of vaginal bleeding in the third trimester without any preceding rupture of membranes.
Ultrasound showed a retroplacental clot consistent with premature separation of the placenta.
Premature separation of placenta, unspecified, third trimester.
Patient reports no abdominal trauma or significant abdominal pain. Fetal heart rate remains stable, and there are no signs of infection.
The patient was admitted for close monitoring and received a blood transfusion due to mild hemorrhage. She was started on bed rest and given antenatal corticosteroids for fetal lung maturation.
The patient remained stable throughout the hospital stay with no further episodes of bleeding. She was discharged home with strict instructions for activity restriction and a follow-up appointment scheduled in one week.
32 years old
Female
Not specified
ICD Code: O4593
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378387
}
|
The patient is a G2P1 (gravida 2, para 1) female with an unremarkable medical history during the current pregnancy.
The patient presents with irregular contractions that are not increasing in intensity or frequency, with no associated vaginal bleeding or fluid leakage.
Fetal ultrasound shows the fetus in vertex presentation with no signs of distress. Cervical exam reveals no cervical dilation or effacement.
False labor before 37 completed weeks of gestation, third trimester. Verbatim EHR quote justifying the code: 'The patient presents with irregular contractions, no cervical changes suggestive of true labor, and absence of other signs of active labor.'
Patient appears comfortable and is not in distress. Fetal heart rate is within normal limits, and there are no signs of infection.
The patient was reassured about the nature of false labor. Instructions were given for hydration and rest. She was discharged home with a follow-up appointment in one week.
Patient responded well to reassurance and conservative management. She was discharged home in stable condition with precautions to return if symptoms change or worsen.
27
Female
Caucasian
ICD Code: O4703
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378388
}
|
The patient has a history of regular prenatal care visits with no reported complications until the current presentation in the third trimester.
The patient presents with regular uterine contractions occurring before 37 completed weeks of gestation, along with cervical changes indicative of preterm labor.
Ultrasound examination shows fetal viability and confirms the gestational age corresponding to the third trimester.
Preterm labor third trimester with preterm delivery third trimester, not applicable or unspecified. Verbatim EHR quote justifying the code: 'The patient presents with regular uterine contractions before 37 completed weeks of gestation, consistent with preterm labor in the third trimester. Cervical examination reveals effacement and dilation, indicating progression towards preterm delivery in the third trimester.'
The obstetrician notes the presence of contractions and cervical changes consistent with preterm labor and advises close monitoring for progression to preterm delivery.
The patient is administered corticosteroids for fetal lung maturation and tocolytic agents to delay labor. Antenatal magnesium sulfate is initiated for neuroprotection of the preterm fetus.
The patient's symptoms are managed successfully, and she is discharged with instructions for close follow-up to monitor fetal well-being and signs of preterm labor recurrence.
29
Female
Caucasian
ICD Code: O6014X0
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378389
}
|
The patient is a 29-year-old G1P0 female with a full-term pregnancy.
The patient presents with regular uterine contractions but no progress in cervical dilation despite oxytocin administration.
Fetal heart rate monitoring shows no signs of distress. Cervical exam reveals no effacement or descent of the fetus.
Failed medical induction of labor. Verbatim EHR quote justifying the code: 'Failed medical induction of labor documented with regular uterine contractions, lack of cervical dilation progress, and no descent of the fetus.'
Patient's labor was induced due to post-term pregnancy. Despite adequate contractions, there was no cervical change after 12 hours of oxytocin administration.
Increased oxytocin dosage was attempted without improvement. Decision made to proceed with cesarean section due to failed induction.
Patient underwent an uncomplicated cesarean section with delivery of a healthy baby. Mother and baby are stable and discharged home on postoperative day 2.
29 years old
Female
Not specified
ICD Code: O610
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378390
}
|
The patient has a history of primary uterine inertia during a previous delivery.
The patient presents with inadequate progress in labor despite regular contractions.
Continuous monitoring shows prolonged labor without cervical dilation progress.
Secondary uterine inertia. Verbatim EHR quote justifying the code: 'The patient is diagnosed with secondary uterine inertia, characterized by the inadequate progression of labor despite regular contractions, following a history of primary uterine inertia.'
The patient's labor has stalled despite the presence of regular contractions, indicating secondary uterine inertia.
The patient was administered oxytocin to augment labor and improve uterine contractions.
The patient responded well to the oxytocin treatment, and labor progressed adequately. She delivered a healthy baby and was discharged in good condition.
29
Female
Caucasian
ICD Code: O621
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378391
}
|
The patient has a history of uncomplicated pregnancies and deliveries.
The patient presented with a sudden visible umbilical cord during labor, which is a classic sign of cord prolapse.
Upon vaginal examination, the healthcare provider confirmed the presence of cord prolapse.
Labor and delivery complicated by prolapse of cord, not applicable or unspecified (ICD-10-CM code O690XX0).
The patient was immediately taken for an emergency cesarean section to prevent cord compression and ensure the safety of the baby.
Emergency cesarean section performed successfully. Both the mother and the newborn are stable post-operation.
The patient and the newborn were discharged in good condition with appropriate post-operative instructions.
32
Female
Caucasian
ICD Code: O690XX0
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378392
}
|
The patient is a 29-year-old G2P1 female with a history of a previous uncomplicated vaginal delivery.
The patient presented with regular contractions at 39 weeks of gestation. Fetal heart rate monitoring showed no signs of distress.
Ultrasound confirmed a single live intrauterine pregnancy in cephalic presentation. Biophysical profile was normal with adequate amniotic fluid.
Labor and delivery complicated by cord around neck, without compression, not applicable or unspecified. Verbatim EHR quote justifying the code: 'During delivery, a nuchal cord was noted without signs of compression, leading to the assignment of code O6981X0.'
The obstetrician documented the presence of a loose nuchal cord that did not impede the progress of labor. No signs of fetal distress were observed during labor.
The patient underwent a spontaneous vaginal delivery without complications. Active management of the third stage of labor was performed to prevent postpartum hemorrhage.
The patient and newborn were discharged in good condition 48 hours post-delivery. Instructions were given for postpartum care and follow-up.
29
Female
Not specified
ICD Code: O6981X0
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378393
}
|
The patient is a G2P1 28-year-old female with an uneventful prenatal course.
The patient reports pain in the perineal area post-delivery.
Physical examination shows a second-degree perineal laceration.
Second-degree perineal laceration during delivery.
The patient had a vaginal delivery with an episiotomy. Second-degree perineal laceration noted post-delivery.
Suture repair of the perineal laceration performed. Analgesics prescribed for pain management.
Patient recovering well post-repair. Advised on perineal care and follow-up in two weeks.
28
Female
Not specified
ICD Code: O701
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378394
}
|
The patient has a history of normal deliveries without any complications.
The patient presents with pain, swelling, and bruising in the perineal and vulvar area following a recent traumatic incident.
Physical examination shows tenderness, ecchymosis, and edema in the perineum and vulva with no signs of cervical dilation.
Other specified trauma to perineum and vulva. Verbatim EHR quote justifying the code: 'Patient presents with pain, swelling, and bruising in the perineal and vulvar area following a recent traumatic incident.'
Patient reports accidental blunt trauma to the perineum and vulva region. Physical examination reveals ecchymosis and tenderness in the affected area. No signs of active labor or uterine contractions.
The patient was advised on pain management, local care for the trauma, and provided with instructions for home monitoring.
Patient discharged in stable condition with improving symptoms. Advised to follow up if any worsening pain or signs of infection.
32
Female
Caucasian
ICD Code: O7182
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378395
}
|
The patient has a history of uncomplicated pregnancies and deliveries with no prior infections during labor.
The patient presents with a low-grade fever, uterine tenderness, and foul-smelling vaginal discharge.
Laboratory tests show elevated white blood cell count and positive cultures for a common vaginal pathogen.
Infection during labor (O753)
The patient's symptoms and diagnostic tests are consistent with a localized infection during labor. No signs of hemorrhage, trauma, or other obstetric complications are present.
The patient is started on a course of antibiotics, and supportive care is provided to manage symptoms.
The patient responded well to treatment, with resolution of symptoms. She is discharged home with a prescription for oral antibiotics and advised to follow up with her obstetrician if symptoms recur.
29
Female
Caucasian
ICD Code: O753
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378396
}
|
The patient has a history of uncomplicated pregnancies and deliveries.
The patient presented with prolonged labor, uterine atony, and excessive postpartum bleeding.
Laboratory tests showed no evidence of infection or coagulation defects.
Other specified complications of labor and delivery (ICD-10-CM code O7589): Verbatim_EHR_quote_justifying_the_code
The patient experienced a prolonged second stage of labor, leading to uterine atony and postpartum hemorrhage.
The patient was managed with uterine massage, intravenous oxytocin, and blood transfusion.
The patient's condition improved with treatment, and she was discharged home in stable condition.
32
Female
Caucasian
ICD Code: O7589
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378397
}
|
The patient is a 32-year-old female with an uneventful pregnancy and vaginal delivery 5 days ago.
The patient presents with a fever of 102.5°F, tachycardia with a heart rate of 110 bpm, uterine tenderness, and foul-smelling vaginal discharge.
Laboratory tests show leukocytosis with a white blood cell count of 15,000/mm³ and elevated C-reactive protein (CRP) levels.
Puerperal sepsis
Clinical examination reveals signs of systemic infection with localized uterine involvement. Blood cultures are positive for bacterial growth.
The patient is started on intravenous broad-spectrum antibiotics and undergoes uterine evacuation. Supportive therapy for sepsis is initiated.
The patient responded well to treatment, with resolution of fever and improvement in inflammatory markers. She is discharged home with a course of oral antibiotics and advised on signs of infection to monitor at home.
32
Female
Not specified
ICD Code: O85
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378398
}
|
The patient had a cesarean section two weeks ago due to fetal distress.
The patient complains of increasing pain, redness, and swelling around the surgical wound site. She also reports a foul-smelling discharge.
Wound culture shows the presence of Staphylococcus aureus.
Infection of obstetric surgical wound (ICD-10-CM code O860): Infection of obstetric surgical wound
On examination, there are signs of inflammation around the surgical wound. The wound is tender to touch, warm, and erythematous. Purulent discharge is noted. No signs of hemorrhage or coagulation defects.
The patient was started on a course of oral antibiotics, and wound care instructions were given. She was advised to keep the wound clean and dry.
The patient responded well to treatment, with decreased pain and swelling. She was discharged with a prescription for antibiotics and advised to follow up in one week for wound reassessment.
32
Female
Caucasian
ICD Code: O860
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378399
}
|
The patient has a history of one prior cesarean delivery.
The patient presents with increased pain and tenderness at the cesarean incision site.
Physical examination shows separation of the cesarean incision edges without signs of infection.
Disruption of cesarean delivery wound (ICD-10-CM code O900): The cesarean incision edges are separated without signs of infection.
The patient reports increased discomfort at the incision site. Physical examination reveals a visible separation of the cesarean incision edges without erythema or discharge.
The patient was started on oral antibiotics, and wound care instructions were provided. Close monitoring for signs of infection was advised.
The patient responded well to treatment, with improved healing of the cesarean incision. Discharged home with instructions for wound care and a follow-up appointment in one week.
32
Female
Caucasian
ICD Code: O900
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378400
}
|
The patient is a 28-year-old pregnant female in her first trimester with a history of iron deficiency anemia. She has been compliant with prenatal vitamins containing iron.
The patient presents with fatigue, pallor, and shortness of breath on exertion. She denies any history of fever, infections, or other significant symptoms.
Laboratory tests show a low hemoglobin level of 9 g/dL (normal range: 12-16 g/dL) and a low mean corpuscular volume (MCV) of 70 fL (normal range: 80-100 fL). Peripheral blood smear reveals microcytic and hypochromic red blood cells.
Anemia complicating pregnancy, first trimester: The pregnant woman's body requires increased iron for fetal development, leading to an exacerbation of her preexisting iron deficiency anemia.
The patient's symptoms and laboratory findings are consistent with iron deficiency anemia complicating her first-trimester pregnancy. There are no signs of infection, mastitis, viral diseases, or other significant complications.
The patient has been started on oral iron supplements and advised to include more iron-rich foods in her diet. She will have close follow-up with the obstetrics team for monitoring.
28
Female
Not specified
ICD Code: O99011
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378401
}
|
The patient is a 28-year-old female in her third trimester of pregnancy with a history of iron deficiency anemia.
The patient presents with fatigue, pale skin, and shortness of breath on exertion.
Laboratory results show low hemoglobin and hematocrit levels consistent with anemia.
Anemia complicating pregnancy, third trimester. Verbatim_EHR_quote_justifying_the_code: 'Diagnosis: Anemia complicating pregnancy, third trimester.'
The patient's symptoms and lab results are indicative of iron deficiency anemia in the context of pregnancy, warranting close monitoring and iron supplementation.
Prescribed iron supplements and advised dietary modifications rich in iron. Follow-up scheduled in two weeks for reassessment.
28
Female
Not specified
ICD Code: O99013
|
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