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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": 378402
}
|
The patient has a history of autoimmune disorders and previous complications during pregnancy.
The patient presents with fatigue, pale skin, and easy bruising.
Laboratory tests show decreased hemoglobin and hematocrit levels, along with elevated levels of specific autoantibodies.
Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating pregnancy, first trimester. Verbatim EHR quote justifying the code: 'The patient presents with fatigue, pale skin, and easy bruising, along with laboratory findings of decreased hemoglobin and hematocrit levels, indicating a condition involving the blood and immune system during the first trimester of pregnancy.'
The patient's symptoms and lab results are consistent with a condition affecting the blood and immune system during early pregnancy.
The patient is started on iron supplementation and referred to a hematologist for further evaluation and management.
The patient responded well to treatment and was discharged with instructions to continue iron supplements and follow up with the hematologist.
32
Female
Caucasian
ICD Code: O99111
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378403
}
|
The patient has a history of autoimmune disorders and blood-related conditions.
The patient presents with fatigue, easy bruising, and recurrent infections.
Laboratory tests show low platelet count, abnormal white blood cell levels, and elevated inflammatory markers.
Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating pregnancy, second trimester.
The patient's symptoms and lab results are consistent with a diagnosis of blood and immune system disorders complicating the second trimester of pregnancy.
Treatment includes close monitoring of blood counts, administration of immunosuppressive therapy, and consultations with hematology and obstetrics specialists.
The patient showed improvement in platelet counts and white blood cell levels. Discharged with instructions for follow-up with hematology and obstetrics clinics.
32
Female
Caucasian
ICD Code: O99112
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378404
}
|
The patient has a history of blood disorders and immune system issues but no history of infectious diseases, anemia, obesity, or endocrine disorders.
The patient presents with symptoms such as fatigue, easy bruising, and frequent infections, indicative of blood and immune system complications.
Laboratory tests show abnormal blood counts and immune markers consistent with blood disorders and immune system involvement.
Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating pregnancy, third trimester. Verbatim EHR quote justifying the code: 'The patient presents with symptoms of fatigue, easy bruising, and frequent infections along with abnormal blood counts and immune markers.'
Patient appears fatigued during the examination with visible bruising. Laboratory results confirm abnormal blood counts and immune markers.
The patient is started on a treatment plan including iron supplements, immune-modulating therapy, and close monitoring of blood counts.
Patient responded well to treatment and is advised to continue medications at home with follow-up appointments for monitoring.
32
Female
Caucasian
ICD Code: O99113
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378405
}
|
The patient has a history of immune system disorders and blood disorders.
The patient presents with fatigue, easy bruising, and recurrent infections.
Laboratory tests show low platelet count and abnormal white blood cell levels.
Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating childbirth (ICD-10-CM code O9912): The patient presents with fatigue, easy bruising, and recurrent infections. Laboratory tests show low platelet count and abnormal white blood cell levels.
The patient's symptoms and lab results indicate a complex interplay between blood disorders and immune system dysfunction, complicating the childbirth process.
The patient is started on immunosuppressive therapy to manage the immune system disorder and is scheduled for regular blood transfusions to address the blood disorder.
The patient responded well to treatment and is stable for discharge. Close follow-up with the hematologist and immunologist is recommended post-discharge.
32
Female
Caucasian
ICD Code: O9912
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378406
}
|
The patient has a history of obesity and is currently in the second trimester of pregnancy.
The patient reports weight gain, increased abdominal size due to pregnancy, and mild shortness of breath on exertion.
BMI of 32, ultrasound confirming the pregnancy in the second trimester, and normal blood work showing no signs of anemia or other blood disorders.
Obesity complicating pregnancy, second trimester. Verbatim ICD-10-CM's verbatim_EHR_quote_justifying_the_code: 'Obesity complicating pregnancy, second trimester.'
Patient's weight gain is within expected limits for pregnancy. No signs of anemia or other blood disorders noted. Recommending a balanced diet and regular prenatal check-ups.
Prescribed prenatal vitamins and advised on a healthy diet and regular exercise.
29
Female
Caucasian
ICD Code: O99212
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378407
}
|
The patient has a history of obesity and is currently in the third trimester of pregnancy.
The patient presents with weight gain, edema in lower extremities, shortness of breath, and elevated blood pressure.
Lab results show elevated BMI, proteinuria, and hypertension.
Obesity complicating pregnancy, third trimester. The patient is in the third trimester of pregnancy and has obesity, leading to complications during this period.
The patient's condition requires close monitoring due to the increased risks associated with obesity during pregnancy.
The patient is advised to follow a controlled diet, engage in light physical activity, and monitor blood pressure regularly. Regular antenatal check-ups are recommended to monitor the progression of the pregnancy and manage any complications.
32
Female
Caucasian
ICD Code: O99213
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378408
}
|
The patient has a history of hypothyroidism and gestational diabetes during a previous pregnancy.
The patient presents with fatigue, weight gain, and mild glucose intolerance.
Laboratory tests show elevated TSH levels and abnormal glucose tolerance test results.
Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester. Verbatim EHR quote justifying the code: 'Endocrine, nutritional and metabolic diseases are complicating the current pregnancy in the second trimester.'
The patient's endocrine and metabolic conditions are affecting her pregnancy, requiring close monitoring and management.
Initiated levothyroxine for hypothyroidism and dietary modifications for gestational diabetes. Regular follow-ups are scheduled to monitor the conditions.
The patient was discharged in stable condition with a plan for continued management of her endocrine and metabolic issues throughout the remainder of her pregnancy.
32
Female
Caucasian
ICD Code: O99282
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378409
}
|
The patient has a history of gestational diabetes during the current pregnancy, which was managed with dietary modifications and insulin therapy.
The patient presents with postpartum hyperglycemia, excessive fatigue, and weight loss despite adequate caloric intake.
Laboratory tests show elevated fasting blood glucose levels and glycosylated hemoglobin (HbA1c). Thyroid function tests indicate hypothyroidism.
Endocrine, nutritional and metabolic diseases complicating childbirth: O99284
The patient's symptoms and diagnostic test results are consistent with endocrine and metabolic disturbances following childbirth. The presence of postpartum hyperglycemia, fatigue, weight loss, and hypothyroidism support the diagnosis of O99284.
The patient is started on levothyroxine for hypothyroidism and advised on lifestyle modifications to manage postpartum hyperglycemia. A follow-up with an endocrinologist is recommended.
The patient responded well to treatment and education regarding her conditions. She is stable for discharge with close outpatient follow-up planned.
32
Female
Caucasian
ICD Code: O99284
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378410
}
|
The patient has a history of drug use disorder and is currently in the second trimester of pregnancy.
The patient presents with anxiety, insomnia, weight loss, and dilated pupils.
Urine drug screening is positive for opioids and benzodiazepines.
Drug use complicating pregnancy, second trimester. Verbatim_EHR_quote_justifying_the_code: 'Patient is diagnosed with Drug use complicating pregnancy, second trimester based on the history of drug use disorder, current pregnancy status, symptoms of anxiety, insomnia, weight loss, dilated pupils, and positive urine drug screening for opioids and benzodiazepines.'
The patient appears restless and agitated, with signs of opioid and benzodiazepine intoxication. Obstetric ultrasound shows no fetal anomalies.
The patient is referred to the addiction medicine specialist for further management. A treatment plan including counseling, opioid replacement therapy, and prenatal vitamins is initiated.
The patient's condition is stable, and she is scheduled for regular follow-up visits with the obstetrician and addiction medicine specialist.
27
Female
Caucasian
ICD Code: O99322
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378411
}
|
The patient has a history of drug use disorder and is currently in the third trimester of pregnancy.
The patient presents with anxiety, insomnia, and mild hypertension.
Urine toxicology screening positive for opioids and benzodiazepines.
Drug use complicating pregnancy, third trimester. The use of specified drugs during the third trimester of pregnancy is associated with adverse effects on the fetus, leading to this diagnosis.
The patient reports a history of substance abuse and acknowledges ongoing drug use during pregnancy. Fetal monitoring shows no current signs of distress.
The patient is referred to a substance abuse counselor for therapy. Close monitoring of fetal development and growth is recommended.
The patient is discharged with instructions for regular prenatal check-ups and continued monitoring of drug use. A follow-up appointment is scheduled in two weeks.
28
Female
Caucasian
ICD Code: O99323
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378412
}
|
The patient has a history of tobacco use and is currently in the third trimester of pregnancy.
The patient reports no specific symptoms related to endocrine, nutritional, metabolic diseases, drug use, mental disorders, or diseases of the nervous system.
No abnormal diagnostic test results were noted.
Smoking (tobacco) complicating pregnancy, third trimester. Verbatim ICD-10-CM's verbatim_EHR_quote_justifying_the_code: 'Smoking (tobacco) complicating pregnancy, third trimester.'
Patient counseled on the risks of smoking during pregnancy and provided with resources for smoking cessation.
Recommendation for smoking cessation programs and follow-up with obstetrician for prenatal care.
The patient was discharged in stable condition with instructions to follow up with the obstetrics clinic for continued prenatal care.
28
Female
Caucasian
ICD Code: O99333
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378413
}
|
The patient has a history of anxiety disorder and depression, both well-controlled with therapy and medication.
The patient reports increased anxiety, mood swings, and difficulty sleeping since becoming pregnant.
No specific diagnostic tests were performed as the diagnosis was based on clinical evaluation and patient history.
Other mental disorders complicating pregnancy, first trimester. Verbatim EHR quote justifying the code: The patient presents with increased anxiety, mood swings, and difficulty sleeping since becoming pregnant, consistent with a diagnosis of other mental disorders complicating pregnancy, first trimester.
Patient appears anxious during the consultation, with a noticeable change in mood compared to previous visits. No signs of substance abuse or neurological deficits observed.
Started the patient on cognitive-behavioral therapy sessions and adjusted the current medication regimen to ensure safety during pregnancy.
Patient discharged in stable condition with a follow-up scheduled in two weeks to monitor treatment response and pregnancy progress.
29
Female
Caucasian
ICD Code: O99341
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378414
}
|
The patient has a history of anxiety disorder and depression, both of which have been managed with therapy and medication.
The patient reports increased anxiety and mood swings since becoming pregnant in the second trimester. She also experiences trouble sleeping and loss of appetite.
Lab tests show no abnormalities. A mental health assessment confirmed the presence of anxiety and depression.
Other mental disorders complicating pregnancy, second trimester
The patient presents with worsening anxiety and mood symptoms during the second trimester of pregnancy. These symptoms are significantly impacting her daily functioning. No signs of substance use or smoking were observed.
The patient was referred to a psychiatrist for further evaluation and management. She was prescribed an adjusted dosage of her current antidepressant medication and scheduled for regular therapy sessions.
28
Female
Caucasian
ICD Code: O99342
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378415
}
|
The patient has a history of anxiety and depression, which have been managed with psychotherapy and medication.
The patient presents with increased anxiety, mood swings, and difficulty coping with the process of childbirth.
Mental health assessment indicated moderate to severe anxiety and depression.
Other mental disorders complicating childbirth. The patient exhibits increased anxiety, mood swings, and difficulty coping with the process of childbirth, consistent with a pre-existing history of anxiety and depression exacerbated by the current situation.
The patient's mental health condition has significantly worsened in the context of childbirth, requiring close monitoring and intervention.
The patient is started on an adjusted medication regimen for anxiety and depression, in addition to increased psychotherapy sessions to support her through the childbirth process.
Upon discharge, the patient's mental health condition has shown improvement with the adjusted treatment plan. She is advised to continue therapy and follow up with the mental health specialist postpartum.
32
Female
Caucasian
ICD Code: O99344
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378416
}
|
The patient is a 28-year-old pregnant woman in her first trimester, G1P0. She has a history of migraines but no other significant medical issues.
The patient presents with severe headaches, blurred vision, and dizziness. She reports experiencing tingling sensations in her hands and feet.
MRI of the brain shows no abnormalities. However, nerve conduction studies reveal mild peripheral neuropathy.
Diseases of the nervous system complicating pregnancy, first trimester. The patient presents with neurological symptoms including severe headaches, blurred vision, dizziness, and peripheral neuropathy.
The patient's symptoms are consistent with a diagnosis of nervous system complications in the context of pregnancy. Close monitoring and further evaluation are recommended to prevent any potential complications.
The patient is advised to take acetaminophen for headache relief and is referred to a neurologist for further management of her peripheral neuropathy.
The patient's symptoms improved with treatment, and she was discharged home with follow-up appointments scheduled with both the obstetrician and neurologist.
28
Female
Caucasian
ICD Code: O99351
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378417
}
|
The patient has a history of migraines but has been stable with occasional episodes controlled by acetaminophen. No other significant medical history reported.
The patient presents with new-onset severe headaches, visual disturbances, and numbness in the left hand during the 22nd week of pregnancy.
MRI of the brain shows no abnormalities. Lumbar puncture results are within normal limits.
Diseases of the nervous system complicating pregnancy, second trimester. The patient presents with severe headaches, visual disturbances, and left hand numbness during the 22nd week of pregnancy, consistent with neurological complications during this period.
The patient's symptoms are indicative of neurological involvement during the second trimester. No signs of pre-eclampsia or other pregnancy-related complications noted. Neurology consult requested.
Started the patient on a low-dose beta-blocker for headache management. Advised rest and hydration. Neurology consult scheduled for further evaluation and management.
29
Female
Caucasian
ICD Code: O99352
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378418
}
|
The patient has a history of migraines but is otherwise healthy during this pregnancy.
The patient presents with severe headaches, visual disturbances, and elevated blood pressure.
MRI showed no abnormalities. Blood tests revealed no signs of preeclampsia.
Diseases of the nervous system complicating pregnancy, third trimester: The patient presents with severe headaches, visual disturbances, and elevated blood pressure, consistent with a diagnosis of Diseases of the nervous system complicating pregnancy, third trimester. These symptoms are not indicative of other neurological or mental disorders but are specific to nervous system complications during pregnancy.
The patient reports no history of seizures or other neurological conditions. Neurological examination showed no focal deficits. Blood pressure monitoring and close observation are recommended.
The patient was advised to rest, stay hydrated, and monitor blood pressure daily. Follow-up in one week is scheduled.
The patient's symptoms improved with rest and hydration. Blood pressure remained stable within normal limits. The patient was discharged with instructions for home monitoring and to return if symptoms worsen.
31
Female
Caucasian
ICD Code: O99353
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378419
}
|
The patient has a history of uncomplicated pregnancies and deliveries with no prior neurological conditions.
The patient presents with severe headache, blurred vision, and seizures following childbirth.
MRI shows signs of postpartum cerebral venous thrombosis.
Diseases of the nervous system complicating childbirth. The patient developed postpartum cerebral venous thrombosis, leading to severe headache, blurred vision, and seizures.
The patient's symptoms started within 48 hours post-delivery. Neurological examination revealed focal neurological deficits consistent with cerebral venous thrombosis.
The patient was started on anticoagulant therapy and closely monitored for any neurological deterioration. Pain management and antiepileptic medications were also initiated.
The patient showed improvement with treatment and was discharged with a plan for outpatient follow-up to monitor the resolution of cerebral venous thrombosis and to adjust medications as needed.
32
Female
Caucasian
ICD Code: O99354
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378420
}
|
The patient has a history of uncomplicated pregnancies and deliveries with no prior history of circulatory system issues.
The patient presented with postpartum hypertension, chest pain, and shortness of breath following delivery.
Lab results indicated elevated blood pressure, troponin levels within normal limits ruling out cardiac events, and an echocardiogram showing signs of postpartum cardiomyopathy.
Diseases of the circulatory system complicating the puerperium.
The patient's symptoms and diagnostic test results are consistent with postpartum cardiomyopathy, a form of heart failure that occurs during the last month of pregnancy or up to five months after giving birth.
The patient was started on heart failure medications, including ACE inhibitors and beta-blockers, and was closely monitored for any signs of worsening heart function.
The patient responded well to treatment, and her symptoms improved. She was discharged with a follow-up appointment scheduled with cardiology in two weeks.
32
Female
Caucasian
ICD Code: O9943
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378421
}
|
The patient is a 28-year-old pregnant female in her second trimester with a history of asthma.
The patient presents with worsening shortness of breath, wheezing, and coughing, especially during physical activity. She denies any chest pain, palpitations, or numbness/tingling.
Pulmonary function tests show a decrease in FEV1 and FVC, consistent with asthma exacerbation. Chest X-ray is clear without any signs of pneumonia or pleural effusion.
Diseases of the respiratory system complicating pregnancy, second trimester. Verbatim EHR quote justifying the code: 'Pregnant female presenting with worsening shortness of breath, wheezing, and coughing, consistent with asthma exacerbation in the second trimester.'
Patient's asthma symptoms have worsened during the second trimester, requiring adjustment of her maintenance inhaler therapy. She is responding well to the treatment plan.
Prescribed albuterol inhaler for acute symptom relief and increased frequency of budesonide/formoterol maintenance inhaler. Advised on asthma triggers to avoid exacerbations.
28
Female
Not specified
ICD Code: O99512
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378422
}
|
The patient has a history of mild asthma controlled with albuterol inhaler as needed.
The patient presents with worsening shortness of breath, wheezing, and coughing, especially at night.
Pulmonary function tests show a decrease in FEV1, indicating worsening asthma. Chest X-ray is clear, ruling out pneumonia.
Diseases of the respiratory system complicating pregnancy, third trimester. The patient's asthma symptoms have worsened during pregnancy, requiring medical intervention.
Patient reports that symptoms started around the 28th week of pregnancy. No history of fever, chest pain, or sputum production. Oxygen saturation is 96% on room air.
Prescribed a short course of oral corticosteroids to manage asthma exacerbation. Advised on asthma triggers and proper inhaler technique. Follow-up scheduled in two weeks.
29
Female
Caucasian
ICD Code: O99513
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378423
}
|
The patient has a history of gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS).
The patient presents with epigastric pain, bloating, and occasional heartburn.
Upper endoscopy showed mild gastritis with no evidence of ulcers. Blood tests revealed normal pancreatic enzyme levels.
Diseases of the digestive system complicating pregnancy, second trimester. Verbatim_EHR_quote_justifying_the_code: 'The patient, in her second trimester of pregnancy, presents with epigastric pain, bloating, and occasional heartburn, along with a history of GERD and IBS. Diagnostic tests showed mild gastritis and normal pancreatic enzyme levels.'
The patient's symptoms are consistent with her known history of GERD and IBS. No signs of acute gastrointestinal conditions were noted.
Prescribed antacids for symptom relief and advised dietary modifications to manage GERD and IBS during pregnancy.
The patient responded well to treatment and was discharged with instructions for follow-up with her obstetrician and gastroenterologist.
32
Female
Caucasian
ICD Code: O99612
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378424
}
|
The patient has a history of gastroesophageal reflux disease (GERD) managed with lifestyle modifications and occasional antacids.
The patient presents with epigastric discomfort, acid reflux, and occasional regurgitation, all worsening in the third trimester of pregnancy.
Upper gastrointestinal endoscopy revealed mild esophagitis and a hiatal hernia.
Diseases of the digestive system complicating pregnancy, third trimester. The patient presents with worsening epigastric discomfort, acid reflux, and regurgitation in the third trimester of pregnancy, with findings of mild esophagitis and a hiatal hernia on upper gastrointestinal endoscopy.
The patient's symptoms are consistent with the exacerbation of pre-existing GERD due to the physiological changes of pregnancy. Management includes dietary recommendations, elevation of the head of the bed, and antacids as needed.
The patient was advised on dietary modifications to alleviate symptoms, instructed on positional therapy, and prescribed antacids for symptom relief.
The patient's symptoms improved with conservative management. She was discharged with instructions for lifestyle modifications and follow-up with the gastroenterologist postpartum.
32
Female
Caucasian
ICD Code: O99613
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378425
}
|
The patient has a history of uncomplicated pregnancies and deliveries with no prior gastrointestinal issues.
The patient presents with abdominal pain, bloating, and constipation following childbirth.
Abdominal ultrasound shows no abnormalities. Blood tests indicate mild dehydration.
Diseases of the digestive system complicating the puerperium. Verbatim ICD-10-CM quote: 'Diseases of the digestive system complicating the puerperium.'
The patient reports discomfort in the upper abdomen, which worsens after meals. No signs of infection or other complications observed.
Treatment includes hydration therapy, dietary adjustments, and pain management. Close monitoring for any signs of complications.
The patient's symptoms improved with treatment, and she was discharged with instructions for follow-up with a gastroenterologist if symptoms persist.
32
Female
Caucasian
ICD Code: O9963
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378426
}
|
The patient has a history of uncomplicated pregnancies and deliveries without any skin-related issues.
The patient presents with skin redness, swelling, and tenderness in the perineal area following childbirth.
Physical examination shows erythema and edema in the perineal region. No signs of infection are noted.
Diseases of the skin and subcutaneous tissue complicating childbirth (ICD-10-CM code O9972) - Skin redness, swelling, and tenderness in the perineal area postpartum.
The patient reports discomfort and mild pain in the perineal region. No signs of infection are present. Likely a localized inflammatory response to the trauma of childbirth.
Prescribed sitz baths, topical analgesics, and advised on perineal care. Follow-up scheduled in one week.
Patient discharged in stable condition with improving symptoms. Advised to continue sitz baths and follow up as scheduled.
32
Female
Caucasian
ICD Code: O9972
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378427
}
|
The patient has a history of dermatological conditions, including eczema and psoriasis, with exacerbations during pregnancy and the postpartum period.
The patient presents with erythematous patches on the abdomen and thighs, associated with mild pruritus. No respiratory or digestive symptoms reported.
Skin biopsy results indicate inflammatory changes consistent with dermatitis. No abnormalities in respiratory or digestive tests.
Diseases of the skin and subcutaneous tissue complicating the puerperium. Verbatim EHR quote justifying the code: 'Skin biopsy showing inflammatory changes consistent with dermatitis in the postpartum period.'
Patient reports discomfort due to skin lesions. No signs of infection or systemic involvement observed. Dermatology consult recommended for further management.
Prescribed topical corticosteroids for local application. Advised on skincare measures and follow-up with dermatologist in two weeks.
Patient discharged in stable condition with improving skin lesions. Recommended to continue treatment as prescribed and follow up with the dermatologist as scheduled.
32
Female
Caucasian
ICD Code: O9973
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378428
}
|
The patient has a history of Streptococcus B carrier state during previous pregnancies without any complications.
The patient is asymptomatic for respiratory, digestive, skin, or other related complications. No cough, shortness of breath, abdominal pain, skin lesions, or other symptoms present.
Positive culture for Streptococcus B from vaginal swab confirmed during prenatal screening. Negative results for respiratory pathogens and digestive infections.
Streptococcus B carrier state complicating pregnancy.
Patient is a known carrier of Streptococcus B and is asymptomatic. No signs of active infection or complications noted during the current pregnancy.
No specific treatment required for Streptococcus B carrier state during pregnancy. Routine prenatal care and monitoring advised.
32
Female
Caucasian
ICD Code: O99820
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378429
}
|
The patient was born prematurely at 28 weeks gestation and required mechanical ventilation in the neonatal intensive care unit.
The patient presents with chronic respiratory distress, oxygen dependency, and recurrent episodes of wheezing and tachypnea.
Chest X-ray shows hyperinflated lungs with diffuse bilateral opacities consistent with bronchopulmonary dysplasia.
Bronchopulmonary dysplasia originating in the perinatal period (P27.1)
The patient's clinical presentation, prematurity, prolonged oxygen requirement, and characteristic chest X-ray findings are consistent with a diagnosis of bronchopulmonary dysplasia.
The patient is on long-term oxygen therapy, diuretics, bronchodilators, and inhaled corticosteroids to manage symptoms and improve lung function.
The patient is being discharged home with oxygen support and close follow-up with a pulmonologist for ongoing management of bronchopulmonary dysplasia.
6 months
Male
Caucasian
ICD Code: P271
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378430
}
|
The patient has a history of congenital hydrocephalus diagnosed in infancy.
The patient presents with macrocephaly, bulging fontanel, irritability, vomiting, and developmental delays.
CT scan of the head shows enlarged ventricles consistent with hydrocephalus.
Congenital hydrocephalus, unspecified. Verbatim EHR quote justifying the code: 'Patient presents with macrocephaly, bulging fontanel, irritability, vomiting, and CT scan findings of enlarged ventricles.'
The neurosurgeon evaluated the patient and confirmed the diagnosis of congenital hydrocephalus. The patient is scheduled for a ventriculoperitoneal shunt placement.
The patient will undergo a ventriculoperitoneal shunt placement to manage the hydrocephalus.
The patient underwent successful ventriculoperitoneal shunt placement without complications and is stable for discharge.
8 months
Male
Caucasian
ICD Code: Q039
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378431
}
|
The patient has a history of congenital brain malformation diagnosed during prenatal ultrasound screenings.
The patient is asymptomatic and neurologically intact upon examination.
MRI of the brain revealed an unspecified congenital malformation affecting the brain structure.
Congenital malformation of brain, unspecified (Q049): The patient presents with an unspecified congenital malformation of the brain structure, as confirmed by MRI imaging.
The patient's neurological examination is within normal limits, and there are no signs of hydrocephalus, microcephaly, or other specific brain malformations.
No specific treatment is required at this time given the patient's asymptomatic and stable condition. Routine follow-up with a neurologist is recommended.
The patient was discharged home in good condition with recommendations for regular follow-up visits with a neurologist to monitor the congenital brain malformation.
3 months
Female
Caucasian
ICD Code: Q049
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378432
}
|
The patient has a history of prenatal folic acid deficiency, known to be a risk factor for neural tube defects.
The patient presents with motor and sensory deficits in the lower extremities, bowel and bladder dysfunction, and a sacral dimple.
MRI of the lumbar spine shows a meningocele at the L5-S1 level consistent with Spina bifida.
Spina bifida, unspecified
Physical examination revealed a visible sacral dimple and neurological deficits in the lower limbs. MRI findings confirm the presence of a meningocele at the L5-S1 level, consistent with Spina bifida.
Surgical consultation for repair of the meningocele and multidisciplinary follow-up for long-term management.
The patient is stable post-surgery and will be followed up in the neurosurgery clinic for further evaluation and care.
3 months
Female
Caucasian
ICD Code: Q059
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378433
}
|
The patient has a history of chronic headaches, dizziness, and difficulty with balance.
The patient presents with chronic headaches, dizziness, difficulty with balance, and numbness in the hands.
MRI of the brain showed herniation of the cerebellar tonsils below the foramen magnum without spina bifida or hydrocephalus.
Arnold-Chiari malformation without mention of spina bifida or hydrocephalus.
The patient's symptoms are consistent with Arnold-Chiari syndrome without evidence of spina bifida or hydrocephalus. The diagnostic imaging confirms the herniation of the cerebellar tonsils without associated findings of spina bifida or hydrocephalus.
The patient was started on acetaminophen for headache management and referred to neurosurgery for further evaluation.
The patient was discharged in stable condition with a follow-up appointment scheduled with the neurosurgery department.
42
Female
Caucasian
ICD Code: Q07.00
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378434
}
|
The patient has no history of eye trauma, surgeries, or congenital eye abnormalities.
The patient presents with bilateral absence of iris, leading to photophobia and glare sensitivity.
Ophthalmologic examination reveals bilateral absence of the iris with otherwise normal eye structures.
Absence of iris (Q131): Absence of iris is a rare congenital condition where the iris is completely missing. This is supported by the ophthalmologic examination findings showing bilateral absence of the iris.
The patient reports discomfort in bright light conditions, consistent with photophobia due to absence of the iris. Ophthalmologic examination confirms the absence of the iris in both eyes.
Prescription of tinted glasses to alleviate photophobia symptoms. Referral to low vision rehabilitation services for visual aids and support.
The patient was discharged with instructions to follow up with the ophthalmologist for regular eye examinations and adjustments to visual aids as needed.
32
Female
Caucasian
ICD Code: Q131
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378435
}
|
The patient has a history of recurrent respiratory infections and fatigue.
The patient presents with fatigue, shortness of breath, and abnormal heart sounds.
Echocardiography revealed the presence of an atrial septal defect.
Atrial septal defect (ASD) is a congenital heart defect characterized by a hole in the wall (septum) that separates the upper chambers of the heart (atria). The verbatim_EHR_quote_justifying_the_code: 'Echocardiography revealed the presence of an atrial septal defect.'
On examination, the patient had a systolic ejection murmur and a fixed split-second heart sound.
The patient is scheduled for a cardiac catheterization procedure to assess the defect for possible closure.
The patient's condition is stable post-procedure, and arrangements have been made for follow-up care.
35
Female
Caucasian
ICD Code: Q211
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378436
}
|
The patient has a known history of aortic valve stenosis since birth, with regular cardiology follow-ups.
The patient reports occasional chest pain on exertion and fatigue, which have been progressively worsening over the past few months.
Echocardiography shows severe stenosis of the aortic valve with a peak velocity of 4.2 m/s and a mean pressure gradient of 50 mmHg.
Congenital stenosis of aortic valve (Q230): The patient presents with severe aortic valve stenosis, confirmed by echocardiography.
The patient's physical examination reveals a systolic ejection murmur in the aortic area and diminished heart sounds. There are no signs of heart failure or other congenital heart defects.
The patient is scheduled for aortic valve replacement surgery due to the severity of the stenosis. In the meantime, the patient is started on beta-blockers for symptom management.
The patient underwent successful aortic valve replacement surgery without complications and is recovering well. Discharge instructions include cardiac rehabilitation and follow-up appointments with the cardiology team.
32
Male
Caucasian
ICD Code: Q230
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378437
}
|
The patient has a known history of congenital heart defects, including aortic valve abnormalities.
The patient presents with symptoms of exercise intolerance, fatigue, and palpitations, suggestive of aortic valve insufficiency.
Echocardiography reveals aortic valve regurgitation and dilatation of the left ventricle.
Congenital insufficiency of aortic valve. The aortic valve is insufficient due to a congenital defect, leading to regurgitation and left ventricular dilatation.
The patient's history of congenital heart defects, along with the echocardiographic findings of aortic valve regurgitation and left ventricular dilatation, support the diagnosis of congenital insufficiency of the aortic valve.
The patient is started on beta-blockers to manage symptoms and is scheduled for regular cardiology follow-ups.
The patient's symptoms have improved with treatment, and arrangements have been made for ongoing cardiology care post-discharge.
32
Male
Caucasian
ICD Code: Q231
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378438
}
|
The patient has a history of congenital heart malformations and has undergone corrective heart surgery in infancy.
The patient is asymptomatic and is being evaluated for routine follow-up of their known heart condition.
Echocardiogram shows residual abnormalities in the heart structure consistent with the previous diagnosis.
Other specified congenital malformations of heart (Q248): The heart malformations in this patient are not classifiable to any other specific category of congenital heart malformations.
The patient is stable and asymptomatic, with no new complaints. Follow-up is recommended in six months.
No active treatment is required at this time. The patient is advised to continue regular follow-up visits with the cardiologist.
The patient is discharged in good condition with instructions to follow up with the cardiology clinic as scheduled.
32
Female
Caucasian
ICD Code: Q248
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378439
}
|
The patient has a history of unexplained fatigue, shortness of breath on exertion, and recurrent respiratory infections.
The patient presents with elevated blood pressure in the upper extremities and low blood pressure in the lower extremities, weak femoral pulses, and a heart murmur.
Echocardiogram revealed a narrowing of the aorta distal to the left subclavian artery.
Coarctation of aorta (Q251): Aortic narrowing typically distal to the left subclavian artery.
The patient shows signs of hypertension in the upper extremities and weak or delayed pulses in the lower extremities, consistent with coarctation of the aorta.
Surgical correction of the aortic narrowing is planned to relieve the obstruction and improve blood flow.
The patient underwent successful surgery to repair the coarctation of the aorta and is stable for discharge. Follow-up with cardiology is recommended for ongoing management.
8 years old
Male
Caucasian
ICD Code: Q251
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378440
}
|
The patient has a history of congenital heart defects in the family, but no personal history of heart conditions or surgeries.
The patient presented with chest pain, shortness of breath, and a pulsatile mass in the abdomen.
CT angiography revealed a fusiform aneurysm involving the aortic root and ascending aorta, measuring 5.6 cm in diameter.
Congenital aneurysm of aorta (ICD-10-CM code Q2543): Aneurysm of the aorta, congenital
The patient's symptoms and imaging findings are consistent with a congenital aneurysm of the aorta. No other congenital heart defects or malformations were observed.
The patient was started on beta-blockers for blood pressure control and referred to a cardiothoracic surgeon for further evaluation and possible surgical intervention.
The patient was discharged in stable condition with close follow-up recommended for monitoring the aneurysm size and cardiac function.
45
Male
Caucasian
ICD Code: Q2543
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378441
}
|
The patient has no prior history of congenital heart defects or vascular malformations.
The patient presented with recurrent headaches and episodes of sudden confusion and dizziness.
MRI of the brain revealed an arteriovenous malformation with no specific site identified.
Arteriovenous malformation, site unspecified (Q27.30)
The patient's symptoms and MRI findings are consistent with an arteriovenous malformation without indication of a specific site. No other congenital heart defects or vascular malformations were detected.
The patient was referred to a neurosurgeon for further evaluation and treatment planning.
The patient was discharged in stable condition for outpatient follow-up with the neurosurgery team.
42
Female
Caucasian
ICD Code: Q27.30
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378442
}
|
The patient has a history of recurrent headaches and dizziness, but no prior cardiovascular conditions.
The patient presented with pulsatile tinnitus and localized swelling in the right forearm.
MRI angiography revealed an arteriovenous malformation in the right forearm without involvement of cerebral vessels.
Arteriovenous malformation, other site. Verbatim EHR quote justifying the code: 'MRI angiography confirmed the presence of an arteriovenous malformation in the right forearm, distinct from cerebral involvement.'
The patient denies any history of cerebral vascular issues. Physical examination shows a palpable thrill and bruit over the right forearm. No neurological deficits noted.
The patient is scheduled for embolization therapy to manage the arteriovenous malformation.
The patient responded well to treatment and was discharged with a follow-up appointment in two weeks.
42
Female
Caucasian
ICD Code: Q2739
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378443
}
|
The patient has a history of respiratory issues since birth, with recurrent episodes of stridor and respiratory distress.
The patient presents with inspiratory stridor, difficulty breathing, and a barking cough. There are no symptoms related to aorta, great veins, cerebral vessels, gastrointestinal or peripheral vascular system, renal, intestinal, bile ducts, liver, pancreas, or urinary system malformations.
Flexible bronchoscopy revealed a collapse of the tracheal walls during expiration, confirming the diagnosis of tracheomalacia.
Other congenital malformations of trachea (Q321) - The trachea is soft and collapses during expiration, causing respiratory symptoms. This diagnosis specifically indicates tracheal malformations, justifying the target ICD code Q321.
The patient's symptoms and diagnostic test results are consistent with tracheomalacia, a congenital malformation of the trachea. No findings suggestive of aortic, cerebral, gastrointestinal, or other systemic malformations were observed.
The patient was started on inhaled bronchodilators to help with breathing and referred to a pediatric pulmonologist for further management.
The patient showed improvement with treatment and was discharged home with instructions for follow-up with the pulmonologist in two weeks.
9 months
Male
Caucasian
ICD Code: Q321
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378444
}
|
The patient has a history of recurrent respiratory infections and chronic respiratory distress since infancy.
The patient presents with chronic wheezing, shortness of breath, and difficulty breathing exacerbated by physical activity.
Pulmonary function tests show evidence of expiratory airflow limitation consistent with bronchomalacia.
Congenital bronchomalacia
The patient's symptoms and diagnostic test results are indicative of congenital bronchomalacia, with no signs of tracheal involvement or other vascular malformations.
Started the patient on inhaled bronchodilators and recommended pulmonary rehabilitation therapy.
The patient responded well to treatment and was discharged with instructions for follow-up pulmonary function tests in three months.
2 years old
Male
Caucasian
ICD Code: Q322
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378445
}
|
The patient has no significant past medical history related to gastrointestinal issues.
The patient presented with abdominal pain, rectal bleeding, and signs of intestinal obstruction.
Abdominal ultrasound revealed a hypertrophic and displaced Meckel's diverticulum. Technetium-99m pertechnetate scintigraphy (Meckel's scan) showed ectopic gastric mucosa within the diverticulum.
Meckel's diverticulum (displaced) (hypertrophic) as evidenced by abdominal ultrasound and Technetium-99m pertechnetate scintigraphy.
The patient's symptoms and diagnostic tests are consistent with Meckel's diverticulum. Surgical consultation for diverticulectomy has been arranged.
The patient is being prepared for surgical removal of the Meckel's diverticulum.
The patient underwent successful diverticulectomy without complications and is recovering well postoperatively.
35
Male
Caucasian
ICD Code: Q430
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378446
}
|
The patient has a history of prenatal ultrasound showing abnormal intestinal positioning.
The patient presents with abdominal distension and bilious vomiting.
Abdominal X-ray reveals a fixed loop of intestine in the right upper quadrant.
Congenital malformations of intestinal fixation (Q433): The intestines are fixed in an abnormal position due to incomplete rotation during embryonic development.
The patient's symptoms and diagnostic tests are consistent with congenital malformations of intestinal fixation. Surgical consultation has been requested for further evaluation and management.
Nasogastric decompression initiated. Surgical intervention planned for intestinal repositioning.
The patient underwent successful surgical correction of the fixed intestinal segment and is recovering well without complications.
2 weeks old
Female
Caucasian
ICD Code: Q433
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378447
}
|
The patient has a history of intestinal malformations since birth, with previous surgical interventions to address related complications.
The patient presents with recurrent episodes of abdominal pain, bloating, and difficulty passing stools.
Abdominal ultrasound revealed structural anomalies in the intestine consistent with congenital malformations.
Other specified congenital malformations of intestine (Q438): The patient has congenital malformations of the intestine, leading to recurrent abdominal symptoms and confirmed by imaging studies.
The patient's symptoms and imaging findings are consistent with congenital malformations of the intestine, requiring further evaluation and management.
The patient was started on a regimen of bowel rest, pain management, and scheduled for a surgical consultation to discuss potential interventions.
The patient was discharged in stable condition with close follow-up recommended to monitor symptoms and plan for potential surgical interventions.
32
Female
Caucasian
ICD Code: Q438
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378448
}
|
The patient has a history of chronic abdominal pain and recurrent episodes of pancreatitis.
The patient presents with abdominal pain, nausea, and vomiting.
Abdominal ultrasound shows dilatation of the pancreatic duct.
Other congenital malformations of pancreas and pancreatic duct (Q453)
The patient has a long-standing history of pancreatic issues, including recurrent pancreatitis and evidence of pancreatic duct dilatation on imaging.
The patient was started on pancreatic enzyme replacement therapy and advised on dietary modifications.
The patient responded well to treatment and was discharged with instructions for follow-up with a gastroenterologist.
42
Female
Caucasian
ICD Code: Q453
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378449
}
|
The patient has no history of congenital malformations or abnormalities other than the current issue of Hypospadias, unspecified.
The patient presents with the primary symptom of abnormal urethral opening on the underside of the penis, consistent with Hypospadias.
Genital examination revealed the atypical urethral opening position. Ultrasound confirmed the diagnosis of Hypospadias without any other associated anomalies.
Hypospadias, unspecified - The urethral meatus opens on the ventral side of the penis. This is consistent with the diagnosis of Hypospadias, unspecified (Q549).
The patient's medical history and physical examination findings are indicative of isolated Hypospadias, without any other congenital abnormalities noted.
Surgical correction of the Hypospadias was recommended and scheduled.
The patient underwent successful surgical correction of the Hypospadias and was discharged in stable condition with appropriate follow-up instructions.
3 years old
Male
Caucasian
ICD Code: Q549
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378450
}
|
The patient has a history of prenatal ultrasound showing absence of one kidney.
No specific symptoms reported as this is a congenital condition.
Prenatal ultrasound confirmed unilateral renal agenesis.
Unilateral renal agenesis as the primary diagnosis.
Patient's condition is consistent with unilateral renal agenesis based on imaging results.
No specific treatment required for unilateral renal agenesis. Advised regular follow-ups.
Patient discharged in stable condition. Advised to continue monitoring for any potential complications.
32
Female
Caucasian
ICD Code: Q600
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378451
}
|
The patient has no significant past medical history related to renal or other congenital abnormalities.
The patient presented with mild intermittent flank pain on the left side. No hematuria, urinary frequency, or other urinary symptoms reported.
Ultrasound revealed a single anechoic cyst in the upper pole of the left kidney, measuring 4 cm in diameter. No other abnormalities detected.
Congenital single renal cyst (Q6101) - A single renal cyst is a common benign condition that typically presents as an incidental finding on imaging studies. It is characterized by a well-defined, round fluid-filled structure within the kidney.
The patient's symptoms and imaging findings are consistent with a congenital single renal cyst. No evidence of polycystic kidney disease or other renal abnormalities.
The patient was advised on conservative management with regular follow-up imaging to monitor the cyst's size and any potential complications.
The patient was discharged in stable condition with instructions for follow-up imaging in six months to reassess the renal cyst.
42
Female
Caucasian
ICD Code: Q6101
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378452
}
|
The patient has a family history of polycystic kidney disease.
The patient presents with flank pain, hematuria, and hypertension.
Ultrasound shows enlarged kidneys with multiple cysts.
Polycystic kidney, unspecified (Q613): The patient presents with flank pain, hematuria, and hypertension. Family history of polycystic kidney disease. Ultrasound shows enlarged kidneys with multiple cysts.
Patient's symptoms and family history are consistent with polycystic kidney disease. Diagnostic ultrasound confirms the presence of multiple kidney cysts.
Prescribed pain management for flank pain and initiated monitoring for hypertension. Referred to nephrology for further management of polycystic kidney disease.
54
Female
Caucasian
ICD Code: Q613
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378453
}
|
The patient has a family history of kidney disorders, including Medullary cystic kidney disease. No history of liver or pancreatic diseases.
The patient presents with flank pain, hypertension, and progressive kidney dysfunction.
Ultrasound shows small cysts in the medulla of both kidneys and impaired kidney function.
Medullary cystic kidney disease (Q615) is a hereditary renal tubular disorder characterized by small cysts in the medulla of both kidneys, leading to progressive renal insufficiency and hypertension.
Patient's renal function deteriorated over the last year with persistent hypertension. Ultrasound confirms the presence of medullary cysts and impaired kidney function.
Initiated treatment with ACE inhibitors to manage hypertension and referred to a nephrologist for further management.
The patient was discharged with close follow-up with the nephrology team for ongoing management of Medullary cystic kidney disease.
45
Female
Caucasian
ICD Code: Q615
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378454
}
|
The patient has a history of recurrent urinary tract infections and flank pain.
The patient presents with severe left flank pain, hematuria, and signs of urinary obstruction.
Ultrasound shows hydronephrosis and hydroureter on the left side.
Other obstructive defects of renal pelvis and ureter
Patient likely has a ureteropelvic junction obstruction causing the symptoms. No other congenital anomalies or cystic diseases are evident.
Patient was started on alpha-blockers to help with ureteral relaxation and referred for a urology consultation.
The patient responded well to treatment and was discharged with a follow-up appointment scheduled with the urology department in two weeks.
45
Female
Caucasian
ICD Code: Q6239
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378455
}
|
The patient has no history of congenital malformations involving the pancreas, kidneys, or urinary tract.
The patient presents with recurrent urinary tract infections, flank pain, and hematuria.
Ultrasound shows duplicated ureters with no other structural abnormalities in the genitourinary system.
Duplication of ureter without mention of obstruction (Q625)
The patient's symptoms and diagnostic tests confirm the presence of duplicated ureters without any associated obstructive defects.
The patient was prescribed antibiotics for the urinary tract infection and advised on symptom management.
The patient responded well to treatment and was discharged with recommendations for follow-up with a urologist for further evaluation.
38
Female
Caucasian
ICD Code: Q625
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378456
}
|
The patient has a history of congenital hip deformity since birth.
The patient presents with limited range of motion in the hip joint, asymmetry in leg lengths, and abnormal gait.
X-ray imaging shows dysplastic changes in the hip joint.
Other specified congenital deformities of hip (Q6589): The hip joint shows dysplastic changes on X-ray imaging, consistent with a congenital deformity.
The patient has limited internal rotation of the affected hip, and there is a noticeable leg length discrepancy. X-ray findings reveal abnormal hip joint morphology.
The patient will undergo orthopedic evaluation for possible surgical intervention to correct the hip deformity.
The patient is scheduled for a follow-up with the orthopedic surgeon for further management of the congenital hip deformity.
6 months
Male
Caucasian
ICD Code: Q6589
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378457
}
|
The patient has a known history of pectus excavatum, a chest wall deformity.
The patient reports cosmetic concerns and occasional mild chest discomfort.
Chest X-ray revealed the characteristic concave appearance of the sternum and ribs.
Pectus excavatum (Q676): Pectus excavatum is a chest wall deformity characterized by a concave or depressed appearance of the anterior chest wall.
The patient's physical examination is consistent with the diagnosis of pectus excavatum. No signs of renal abnormalities or musculoskeletal deformities were noted.
Advised the patient on observation and offered a referral to a thoracic surgeon for further evaluation.
The patient was discharged with recommendations for follow-up with a specialist to discuss potential treatment options for pectus excavatum.
17
Male
Caucasian
ICD Code: Q676
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378458
}
|
The patient has a history of congenital spine malformations.
The patient presents with midline defects of the spine, such as spina bifida occulta.
MRI shows abnormalities in the formation of the spine, without evidence of scoliosis.
Other congenital malformations of spine, not associated with scoliosis. Verbatim EHR quote justifying the code: 'Patient diagnosed with other congenital malformations of spine, not associated with scoliosis.'
Patient's physical examination reveals midline bony defects along the spine, consistent with congenital malformations.
The patient is referred to a spine specialist for further evaluation and management.
Patient discharged in stable condition with a follow-up appointment scheduled with the spine specialist.
32
Female
Caucasian
ICD Code: Q7649
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378459
}
|
The patient has a history of reddish-brown spots and blistering on the skin since birth.
The patient presents with itchy skin lesions and Darier's sign is positive upon examination.
Skin biopsy results confirm the presence of mast cells in the skin.
Congenital cutaneous mastocytosis (Q822): The presence of mast cells in the skin is consistent with the diagnosis of congenital cutaneous mastocytosis.
Patient presents with typical skin lesions and Darier's sign, consistent with congenital cutaneous mastocytosis. Biopsy results confirm the diagnosis.
Treatment includes antihistamines for symptom relief and topical corticosteroids for skin inflammation.
The patient responded well to treatment and was discharged in stable condition.
5 years old
Female
Caucasian
ICD Code: Q822
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378460
}
|
The patient has a known history of café-au-lait spots and a family history of neurofibromatosis.
The patient presents with multiple soft, non-tender nodules on the skin, café-au-lait spots, and freckling in the axillary region.
MRI findings reveal multiple neurofibromas along peripheral nerves.
Neurofibromatosis, unspecified (ICD-10-CM code Q8500) - The patient presents with multiple neurofibromas and café-au-lait spots, consistent with a diagnosis of neurofibromatosis.
On examination, multiple discrete neurofibromas were noted on the skin, along with café-au-lait spots. No signs of bilateral vestibular schwannomas were detected.
The patient is referred to a genetic counselor for further evaluation and genetic testing. Symptomatic management and regular follow-up appointments are recommended.
The patient was discharged in stable condition with a follow-up plan in place for ongoing management of neurofibromatosis.
38
Male
Caucasian
ICD Code: Q8500
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378461
}
|
The patient has a known history of neurofibromatosis type 2.
The patient complains of progressive hearing loss, tinnitus, and occasional balance problems.
MRI findings reveal bilateral vestibular schwannomas.
Neurofibromatosis, type 2 (Q8502): Bilateral vestibular schwannomas are characteristic of neurofibromatosis type 2.
The patient presents with classic symptoms of neurofibromatosis type 2, including hearing loss and balance issues. MRI results confirm the presence of bilateral vestibular schwannomas.
The patient is referred to the otolaryngology department for further evaluation and management.
The patient's condition is stable, and further follow-up with the otolaryngologist is recommended.
45
Female
Caucasian
ICD Code: Q8502
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378462
}
|
The patient has a known history of tuberous sclerosis with multiple previous hospital admissions for management.
The patient presents with a history of seizures, cognitive impairment, and facial angiofibromas.
MRI of the brain showed cortical tubers and subependymal nodules. Echocardiography revealed cardiac rhabdomyomas.
Tuberous sclerosis, also known as Bourneville disease, is a genetic disorder characterized by the growth of numerous noncancerous tumors in different parts of the body. The condition is associated with facial angiofibromas, hypopigmented macules, cortical tubers, subependymal nodules, cardiac rhabdomyomas, and renal angiomyolipomas.
The patient's physical examination is consistent with tuberous sclerosis, with the presence of facial angiofibromas and hypopigmented macules. Neurological examination revealed cognitive impairment and a history of seizures.
The patient is started on antiepileptic medication for seizure control and referred to a multidisciplinary team for further management of tuberous sclerosis.
The patient was discharged in stable condition with close follow-up recommended for ongoing management of tuberous sclerosis.
32
Female
Caucasian
ICD Code: Q851
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378463
}
|
The patient has a history of multiple skin lesions since childhood, with occasional episodes of seizures and cognitive difficulties.
The patient presents with multiple café-au-lait spots on the skin, axillary freckling, and Lisch nodules on the iris.
MRI brain scan shows multiple hamartomatous lesions. Genetic testing reveals a mutation in the NF1 gene.
Other phakomatoses, not elsewhere classified (ICD-10-CM code Q858)
Patient shows classic signs of neurofibromatosis type 1, including café-au-lait spots, axillary freckling, Lisch nodules, and hamartomas. Genetic testing confirms the diagnosis.
Initiated referral to a neurologist for seizure management and a dermatologist for monitoring and management of skin lesions.
Patient discharged in stable condition with follow-up appointments scheduled with neurology and dermatology clinics.
38
Male
Caucasian
ICD Code: Q858
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378464
}
|
The patient has a history of multiple café-au-lait spots on the skin since childhood, along with a family history of similar skin findings.
The patient presents with multiple pigmented skin lesions, some of which have irregular borders and vary in size. There are no signs of pectus excavatum, scoliosis, or abdominal wall malformations.
Skin biopsy results indicate the presence of neuroectodermal cells with melanin pigmentation, consistent with phakomatosis.
Phakomatosis, unspecified: Multiple café-au-lait spots and neuroectodermal cells with melanin pigmentation on skin biopsy.
The patient's skin lesions are consistent with a diagnosis of phakomatosis. No other significant findings on physical examination or history to suggest a different phakomatosis syndrome.
Dermatological follow-up for monitoring of skin lesions. Genetic counseling offered to the patient and family.
The patient is stable with no acute concerns. Advised to follow up with dermatology for long-term management of skin lesions.
32
Female
Caucasian
ICD Code: Q859
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378465
}
|
The patient has a history of limb malformations since birth with no other significant medical conditions.
The patient presents with asymmetrical limb lengths, joint contractures, and abnormal positioning of the hands and feet.
X-rays of the limbs show skeletal abnormalities consistent with congenital malformations. Genetic testing is pending.
Congenital malformation syndromes predominantly involving limbs (Q872): Limb malformations predominantly involving the limbs.
Physical examination reveals limb length discrepancies, joint contractures, and hand and foot malformations consistent with a congenital limb deformity syndrome.
The patient is referred to orthopedic surgery for further evaluation and possible corrective interventions.
The patient is stable and discharged with a follow-up appointment in the orthopedic clinic in two weeks.
7 months
Male
Caucasian
ICD Code: Q872
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378466
}
|
The patient has a family history of Marfan syndrome. No history of other significant medical conditions.
The patient presents with tall stature, arachnodactyly, joint hypermobility, and mild scoliosis.
Echocardiography shows aortic root dilation of 4.2 cm.
Marfan syndrome, unspecified. Verbatim EHR quote justifying the code: 'The patient presents with tall stature, arachnodactyly, joint hypermobility, and echocardiographic evidence of aortic root dilation, consistent with the clinical criteria for Marfan syndrome.'
Patient's physical examination revealed typical features of Marfan syndrome including a high-arched palate and positive wrist and thumb signs.
Consultation with a genetic counselor for further evaluation and management. Referral to a cardiologist for ongoing monitoring of aortic root dilation.
The patient was discharged in stable condition with recommendations for regular follow-up with the genetic counselor and cardiologist.
32
Male
Caucasian
ICD Code: Q8740
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378467
}
|
The patient has a history of delayed puberty and primary amenorrhea.
The patient presents with short stature, webbed neck, and lymphedema in the hands and feet.
Karyotype analysis revealed the absence of one X chromosome.
Turner's syndrome, unspecified (Q969)
Physical examination shows characteristic features of Turner's syndrome including short stature, webbed neck, and lymphedema. Karyotype analysis confirmed the diagnosis by revealing the absence of part or all of one X chromosome.
The patient will be referred to an endocrinologist for further management and initiation of growth hormone therapy.
The patient is stable and will follow up with the endocrinologist for ongoing care.
16
Female
Caucasian
ICD Code: Q969
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378468
}
|
The patient has a history of delayed puberty and infertility.
The patient presents with gynecomastia, small testes, and mild intellectual disability.
Karyotype analysis revealed the presence of an extra X chromosome (47,XXY). Testosterone levels are low.
Klinefelter syndrome, unspecified (Q984): The patient presents with gynecomastia, small testes, infertility, and cognitive/developmental delays.
Physical examination shows gynecomastia and small, firm testes. The patient has a BMI within normal limits. Karyotype analysis confirms the diagnosis of Klinefelter syndrome.
The patient will start testosterone replacement therapy to address hypogonadism. Referral to a fertility specialist for assisted reproductive techniques will be arranged.
The patient responded well to treatment and was discharged with a follow-up appointment scheduled in two weeks.
27
Male
Caucasian
ICD Code: Q984
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378469
}
|
The patient has a known history of developmental delays and intellectual disability since childhood. There is no family history of genetic disorders.
The patient presents with mild dysmorphic features including a broad nasal bridge and low-set ears. Additionally, there are no signs of musculoskeletal abnormalities or cardiac defects.
Genetic testing revealed a unique chromosomal abnormality involving a partial deletion of chromosome 15.
Other specified chromosome abnormalities (Q998): Chromosomal abnormality involving a partial deletion of chromosome 15.
The patient's dysmorphic features and developmental delays are consistent with the diagnosis of Other specified chromosome abnormalities. Genetic testing confirmed the specific chromosomal abnormality.
The patient will be referred to a genetic counselor for further evaluation and genetic counseling. Regular developmental assessments and early intervention programs will be recommended.
The patient was discharged in stable condition with a follow-up appointment scheduled with the genetic counselor.
22
Female
Caucasian
ICD Code: Q998
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378470
}
|
The patient has a history of hypertension and hypothyroidism.
The patient reports dizziness, fatigue, and occasional fainting episodes.
Electrocardiogram (ECG) shows a heart rate of 55 beats per minute.
Bradycardia, unspecified. Verbatim EHR quote justifying the code: 'The patient presents with a heart rate of 55 beats per minute, consistent with bradycardia.'
Patient's blood pressure is within normal limits. No signs of heart failure or structural heart abnormalities noted.
The patient was advised to follow up with a cardiologist for further evaluation and management.
The patient was stable throughout the hospital stay and was discharged with instructions to monitor heart rate regularly.
58
Female
Caucasian
ICD Code: R001
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378471
}
|
The patient has a history of occasional episodes of palpitations over the past few months.
The patient reports experiencing a fluttering sensation in the chest, with episodes lasting for a few minutes at a time. No associated chest pain, dizziness, or shortness of breath.
Electrocardiogram (ECG) shows occasional premature atrial contractions (PACs) but is otherwise normal. Blood tests reveal normal electrolyte levels.
Palpitations: The patient presents with a fluttering sensation in the chest, with no associated symptoms such as chest pain, dizziness, or shortness of breath. The ECG shows occasional premature atrial contractions (PACs) but is otherwise unremarkable.
The patient's palpitations seem to be benign in nature, likely related to occasional premature atrial contractions. No signs of structural heart abnormalities on ECG.
Recommendations given to the patient include stress reduction techniques, adequate hydration, and follow-up with a cardiologist for further evaluation if symptoms persist.
The patient's palpitations improved with the recommended measures. Discharged home with instructions to follow up with a cardiologist if symptoms recur or worsen.
45
Female
Caucasian
ICD Code: R002
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378472
}
|
The patient has a known history of occasional palpitations but no prior diagnosis related to heart rhythm abnormalities.
The patient complains of intermittent irregular heartbeats and occasional palpitations. Denies any history of dizziness, syncope, chest pain, shortness of breath, or edema.
Electrocardiogram (ECG) shows occasional premature atrial contractions (PACs) but no sustained arrhythmias. Echocardiogram is normal without any structural abnormalities.
Other abnormalities of heart beat (R008)
The patient presents with intermittent irregular heart rhythms and occasional palpitations. ECG findings reveal occasional premature atrial contractions (PACs) but no sustained arrhythmias. The echocardiogram shows normal cardiac structure and function.
Prescribed low-dose beta-blocker for symptomatic relief and advised lifestyle modifications including stress reduction techniques.
The patient responded well to treatment and symptomatically improved. Discharged with a prescription for a beta-blocker and advised to follow up with a cardiologist in two weeks.
45
Female
Caucasian
ICD Code: R008
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378473
}
|
The patient has a history of occasional heart palpitations but no prior diagnosed heart conditions.
The patient reports intermittent chest discomfort and a faint heart sound on auscultation.
Echocardiogram shows turbulent blood flow in the heart without structural abnormalities.
Cardiac murmur, unspecified. Verbatim EHR quote justifying the code: 'Patient presents with intermittent chest discomfort and a faint heart sound on auscultation, consistent with a cardiac murmur. Echocardiogram reveals turbulent blood flow without structural defects.'
Patient's heart rate is regular, and no signs of heart failure are noted. Recommend follow-up in 6 months for monitoring.
Prescribed low-dose aspirin for chest discomfort and advised lifestyle modifications.
56
Female
Caucasian
ICD Code: R011
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378474
}
|
The patient has a history of seasonal allergies but no history of bleeding disorders or cardiovascular conditions.
The patient presented with recurrent episodes of bright red blood coming from the nose without any associated cough, shortness of breath, or chest pain.
Coagulation studies were within normal limits, ruling out any clotting abnormalities.
Epistaxis (R040): The patient presented with recurrent episodes of bright red blood coming from the nose without any associated symptoms.
Upon examination, the source of bleeding was identified in the anterior nasal septum. No other abnormalities were noted in the ear, nose, and throat examination.
The patient was treated with anterior nasal packing and discharged with instructions for nasal care and follow-up with an otolaryngologist.
The patient responded well to treatment with resolution of bleeding episodes. Discharge instructions include nasal care and follow-up with the otolaryngologist for pack removal.
42
Female
Caucasian
ICD Code: R040
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378475
}
|
The patient has a history of chronic bronchitis and smoking.
The patient presents with coughing up blood (hemoptysis) for the past two days.
Chest X-ray shows infiltrates in the right lower lobe suggestive of pneumonia.
Hemoptysis (R042)
Patient denies any recent trauma or nosebleeds. No signs of dyspnea or chest pain. Oxygen saturation is within normal limits.
Started on antibiotics for suspected pneumonia. Advised smoking cessation and follow-up with pulmonologist.
Patient responded well to treatment, hemoptysis resolved. Discharged home with a prescription for a full course of antibiotics.
58
Male
Caucasian
ICD Code: R042
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378476
}
|
The patient has a history of seasonal allergies and occasional upper respiratory infections.
The patient presented with sudden onset of bright red blood in sputum after a bout of coughing.
Chest X-ray showed no signs of pneumonia or masses. Bronchoscopy revealed active bleeding from the bronchial wall.
Hemorrhage from other sites in respiratory passages (R04.89) - Hemorrhage from respiratory passages
Patient reports no history of trauma or recent surgeries that could explain the bleeding. Vital signs stable, no signs of hemodynamic instability.
Patient was started on intravenous antibiotics and bronchodilators. Bronchial artery embolization was performed to stop the bleeding.
Patient responded well to treatment with cessation of bleeding. Discharged home with a course of oral antibiotics and advised to follow up with pulmonologist in two weeks.
54
Female
Caucasian
ICD Code: R04.89
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378477
}
|
The patient has a history of seasonal allergies but no significant respiratory conditions.
The patient presents with a persistent dry cough for the past week, worsened at night and with minimal sputum production.
Chest X-ray shows clear lung fields with no signs of infection. Complete blood count is within normal limits.
Cough: The patient is diagnosed with cough (R05) based on the presenting symptoms of persistent dry cough with no signs of infection on imaging studies.
The patient denies any chest pain, shortness of breath, or wheezing. No fever reported. Advised on home remedies and follow-up if symptoms persist.
Prescribed over-the-counter cough suppressant and advised on adequate hydration. Follow-up scheduled in two weeks if symptoms persist.
42
Female
Caucasian
ICD Code: R05
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378478
}
|
The patient has a history of congestive heart failure and hypertension.
The patient reports severe difficulty breathing when lying flat, which improves significantly upon sitting up. No cough, wheezing, or chest pain reported.
Chest X-ray shows signs of pulmonary congestion. Echocardiogram reveals reduced ejection fraction.
Orthopnea (ICD-10-CM code: R0601) - The patient experiences significant difficulty breathing when lying flat, which is relieved upon assuming an upright position.
The patient's symptoms are classic for Orthopnea, with a clear exacerbation when lying down and improvement with elevation. No signs of acute respiratory distress or wheezing noted.
Prescribed diuretics to manage fluid overload and advised on sleeping with an elevated upper body.
The patient's condition improved with treatment, and symptoms of Orthopnea significantly reduced. Advised to follow up with cardiology for further management of heart failure.
65
Female
Caucasian
ICD Code: R0601
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378479
}
|
The patient has a history of mild asthma controlled with albuterol inhaler as needed.
The patient presents with sudden onset shortness of breath, worsens with activity, and improves with rest. No cough, wheezing, or orthopnea reported.
Chest X-ray shows clear lung fields with no signs of infection or congestion.
Shortness of breath (R0602) - The patient presents with sudden onset shortness of breath, worsens with activity, and improves with rest. No cough, wheezing, or orthopnea reported.
The patient denies any chest pain, palpitations, or dizziness. Oxygen saturation levels are within normal limits at rest.
Prescribed albuterol inhaler for symptom relief as needed. Advised the patient to follow up if symptoms worsen or persist.
The patient responded well to treatment and reported decreased episodes of shortness of breath. Advised to continue using albuterol inhaler as needed.
45
Female
Caucasian
ICD Code: R0602
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378480
}
|
The patient has a history of seasonal allergies but no significant respiratory conditions.
The patient presents with sudden-onset severe difficulty breathing, tachypnea, and hypoxemia.
Arterial blood gas analysis shows hypoxemia with a decreased PaO2 and increased PaCO2, suggestive of acute respiratory distress.
Acute respiratory distress (ICD-10-CM code: R0603)
The patient appears distressed, with labored breathing, use of accessory muscles, and cyanosis. Lung auscultation reveals diffuse crackles and decreased breath sounds.
The patient was immediately started on high-flow oxygen therapy, bronchodilators, and corticosteroids. Continuous monitoring of vitals and oxygen saturation was initiated.
After 48 hours of intensive treatment, the patient's respiratory distress significantly improved, and oxygen saturation normalized. The patient was discharged with a tapering dose of oral steroids and advised to follow up with a pulmonologist in one week.
45
Female
Caucasian
ICD Code: R0603
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378481
}
|
The patient has a history of asthma and seasonal allergies but no prior history of cardiac or pulmonary conditions.
The patient reports sudden onset shortness of breath, especially when lying flat, which improves upon sitting up. No cough, wheezing, or stridor reported.
Pulmonary function tests show a restrictive pattern with decreased lung volumes. Chest X-ray reveals no acute abnormalities.
Other forms of dyspnea (R0609): The patient presents with sudden onset dyspnea, particularly when lying flat, suggestive of orthopnea. This symptom is a key differentiator for R0609.
The patient denies any chest pain, cough, wheezing, or stridor. Oxygen saturation remains normal at rest and with exertion. No signs of respiratory distress noted during the examination.
Prescribed albuterol inhaler for possible bronchospasm and advised to sleep with an extra pillow for elevation. Follow-up scheduled in two weeks for reassessment.
The patient responded well to treatment and was discharged in stable condition with instructions to continue medications and follow up as scheduled.
45
Female
Caucasian
ICD Code: R0609
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378482
}
|
The patient has a history of asthma and seasonal allergies.
The patient presents with inspiratory high-pitched sound, suprasternal and intercostal retractions, and nasal flaring.
Laryngoscopy shows narrowing of the airway at the level of the larynx.
Stridor (ICD-10-CM code R061): The patient presents with inspiratory high-pitched sound, suprasternal and intercostal retractions, and nasal flaring. Laryngoscopy shows narrowing of the airway at the level of the larynx.
The patient is in mild distress but maintaining oxygen saturation. Stridor is loudest over the neck and upper chest. No signs of epistaxis, hemoptysis, or other bleeding.
The patient was administered racemic epinephrine and monitored closely. Oxygen therapy was initiated, and the patient was kept NPO (nothing by mouth) for observation.
The patient responded well to treatment and was discharged home with instructions for close monitoring and follow-up with an ENT specialist.
7
Male
Caucasian
ICD Code: R061
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378483
}
|
The patient has a history of hypertension and obesity.
The patient reports episodes of breathing that alternate between deep and shallow patterns, especially during sleep, without any associated chest pain, cough, or wheezing.
Polysomnography showed periodic oscillations in respiratory rate during sleep.
Periodic breathing (ICD-10-CM code R063): The patient presents with recurrent episodes of waxing and waning breathing patterns, especially during sleep, without other associated symptoms like hemoptysis, cough, dyspnea, wheezing, or chest pain.
Patient's breathing pattern is characteristic of Periodic breathing, with no signs of respiratory distress or other respiratory conditions.
Prescribed continuous positive airway pressure (CPAP) therapy for managing Periodic breathing.
The patient responded well to CPAP therapy and was discharged in stable condition.
55
Female
Caucasian
ICD Code: R063
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378484
}
|
The patient has a history of gastroesophageal reflux disease (GERD) and anxiety disorder.
The patient presents with persistent involuntary diaphragmatic contractions resulting in a 'hic' sound.
Chest X-ray and blood tests are unremarkable.
Hiccough (ICD-10-CM code R066)
The patient reports no associated symptoms like cough, shortness of breath, or chest pain. The hiccough episodes are not related to any respiratory or cardiac issues.
Prescribed oral medication for GERD and reassurance for anxiety management.
The patient's hiccough resolved with treatment, and no further intervention was needed upon discharge.
42
Female
Caucasian
ICD Code: R066
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378485
}
|
The patient has a history of obesity and hypertension.
The patient reports loud snoring at night, witnessed apneic episodes, excessive daytime sleepiness, and morning headaches.
Polysomnography showed multiple apnea episodes during sleep with an apnea-hypopnea index of 30.
Apnea, not elsewhere classified. Verbatim EHR quote justifying the code: 'The patient presents with loud snoring, witnessed apneic episodes, excessive daytime sleepiness, and morning headaches. Polysomnography confirmed multiple apnea episodes during sleep with an apnea-hypopnea index of 30.'
Patient's BMI is 32, and physical examination revealed enlarged tonsils. No signs of respiratory distress during the examination.
Continuous positive airway pressure (CPAP) therapy initiated. Advised weight loss and follow-up with an otolaryngologist for possible tonsillectomy.
Patient responded well to CPAP therapy, with resolution of daytime sleepiness. Scheduled for follow-up in the sleep clinic in one month.
45
Male
Caucasian
ICD Code: R0681
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378486
}
|
The patient has a history of childhood asthma but has been asymptomatic for the past 10 years.
The patient presents with rapid breathing at a rate of 30 breaths per minute.
Chest X-ray shows clear lung fields with no signs of consolidation or effusion.
Tachypnea, not elsewhere classified. The patient presents with rapid breathing at a rate of 30 breaths per minute, without any other associated respiratory symptoms.
The patient denies any chest pain, wheezing, or shortness of breath. Oxygen saturation is 98% on room air. No signs of respiratory distress are noted.
The patient was provided with oxygen therapy and monitored closely. Albuterol inhaler was prescribed for possible bronchodilation.
The patient responded well to treatment and was discharged home in stable condition with instructions to follow up with their primary care physician in one week.
45
Female
Caucasian
ICD Code: R0682
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378487
}
|
The patient has a history of occasional snoring, especially noted by the partner during sleep.
The patient reports loud snoring during sleep without any witnessed apnea episodes or daytime sleepiness.
Nocturnal polysomnography showed primary snoring without evidence of sleep apnea.
Snoring (R0683): The patient presents with loud snoring during sleep without any other associated symptoms or signs.
The patient denies any history of shortness of breath, orthopnea, wheezing, or chest pain. Physical examination reveals no abnormalities in the respiratory system.
The patient was advised on positional therapy and lifestyle modifications to alleviate snoring.
The patient's condition improved with positional therapy, and no further interventions were deemed necessary upon discharge.
45
Male
Caucasian
ICD Code: R0683
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378488
}
|
The patient has a history of seasonal allergies but no prior respiratory conditions.
The patient reports episodes of irregular breathing patterns characterized by brief pauses in breathing and sudden deep inhalations.
Pulmonary function tests reveal normal lung function with no signs of obstruction or restriction.
Other abnormalities of breathing (R0689): The patient presents with irregular breathing patterns including brief pauses and sudden deep inhalations, not classifiable under other respiratory codes.
The patient's abnormal breathing episodes do not fit the criteria for typical dyspnea, wheezing, or other common respiratory issues. The absence of wheezing, stridor, or signs of respiratory distress distinguishes this case.
Prescribed antihistamines for seasonal allergies. No specific treatment required for the irregular breathing episodes as they are not indicative of a specific respiratory pathology.
The patient's condition remains stable with no acute respiratory distress observed. Advised to follow up if the irregular breathing episodes worsen or increase in frequency.
45
Female
Caucasian
ICD Code: R0689
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378489
}
|
The patient has a history of occasional asthma exacerbations managed with albuterol inhaler as needed. No prior history of pleurisy, pneumonia, or other significant respiratory conditions.
The patient presents with sharp, stabbing chest pain on the right side aggravated by breathing deeply or moving the torso. The pain is associated with a low-grade fever and tenderness of the chest wall muscles.
Chest X-ray shows no signs of pneumonia or pleural effusion. Complete blood count reveals mild leukocytosis with a left shift.
Pleurodynia (R0781): Painful respiration
The patient describes the pain as sharp and worsened by breathing deeply. There are no auscultatory abnormalities noted, ruling out wheezing or stridor. Tenderness is elicited on palpation of the intercostal muscles, supporting the diagnosis of pleurodynia.
Prescribed ibuprofen for pain control and advised on rest. Follow-up in one week if symptoms persist.
The patient's chest pain improved with analgesics, and no signs of respiratory distress were observed at discharge.
38
Female
Caucasian
ICD Code: R0781
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378490
}
|
The patient has a history of occasional acid reflux managed with lifestyle modifications.
The patient complains of sharp and intermittent chest pain exacerbated by deep breathing and movement.
ECG showed normal sinus rhythm with no acute changes. Cardiac enzymes were within normal limits. Chest X-ray revealed no acute abnormalities.
Other chest pain: The chest pain is sharp, intermittent, and worsens with deep breathing and movement. No findings of wheezing, pleurodynia, or other specified abnormalities of breathing.
The patient's chest pain is likely musculoskeletal in nature, possibly due to costochondritis. Advised on pain management and follow-up if symptoms persist or worsen.
Prescribed acetaminophen for pain relief as needed. Recommended warm compresses and gentle stretching exercises for chest wall muscles.
The patient's chest pain improved with medication and conservative measures. Advised to follow up if symptoms recur or if new concerns arise.
45
Female
Caucasian
ICD Code: R0789
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378491
}
|
The patient has a history of asthma and seasonal allergies.
The patient presents with shortness of breath, rapid breathing, and low oxygen saturation levels.
Arterial blood gas analysis shows decreased oxygen levels with a PaO2 of 55 mmHg.
Hypoxemia due to decreased oxygen saturation levels as evidenced by arterial blood gas analysis showing a PaO2 of 55 mmHg.
The patient is tachypneic with a respiratory rate of 28 breaths per minute. Oxygen therapy at 4 liters per minute via nasal cannula has been initiated to improve oxygenation.
The patient is started on albuterol inhaler for bronchodilation and prescribed a short course of oral corticosteroids to manage the underlying asthma exacerbation.
The patient responded well to treatment and showed improved oxygen saturation levels. Discharged home with a prescription for albuterol inhaler and a follow-up appointment with the pulmonologist in two weeks.
45
Female
Caucasian
ICD Code: R0902
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378492
}
|
The patient has a history of asthma and seasonal allergies.
The patient presents with sharp chest pain on the left side that worsens with deep breathing and coughing. The pain is also accompanied by shortness of breath.
Chest X-ray shows left-sided pleural effusion with no signs of pneumonia.
Pleurisy
Upon auscultation, a pleural friction rub was heard over the left lower lung field. The patient's symptoms and imaging results are consistent with Pleurisy.
Prescribed ibuprofen for pain management and advised rest. Follow-up scheduled in two weeks.
The patient responded well to treatment and was discharged in stable condition with instructions to follow up if symptoms worsen.
42
Female
Caucasian
ICD Code: R091
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378493
}
|
The patient has a history of seasonal allergies but no prior history of chronic respiratory conditions.
The patient presents with clear nasal discharge, nasal stuffiness, and occasional sneezing.
Physical examination shows no signs of acute sinusitis or other nasal abnormalities.
Nasal congestion (R0981): The patient presents with clear nasal discharge, nasal stuffiness, and occasional sneezing. There are no signs of acute sinusitis or other nasal abnormalities.
The patient reports worsening symptoms in the morning and at night, with relief experienced after using a saline nasal spray.
Prescribed loratadine for allergies and advised on the use of saline nasal spray as needed.
The patient responded well to treatment and was discharged in stable condition with instructions for follow-up if symptoms persist.
32
Female
Caucasian
ICD Code: R0981
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378494
}
|
The patient has a history of seasonal allergies with occasional episodes of postnasal drip.
The patient presents with a constant sensation of mucus dripping down the back of the throat, causing throat clearing and occasional cough due to postnasal drip.
Nasal endoscopy revealed clear nasal discharge without signs of infection. Pulmonary function tests were within normal limits.
Postnasal drip as the primary diagnosis. Verbatim ICD_10_CM's verbatim_EHR_quote_justifying_the_code: 'Patient presents with a constant sensation of mucus dripping down the back of the throat, causing throat clearing and occasional cough due to postnasal drip.'
The patient reports that symptoms worsen in the mornings and at night. No signs of respiratory distress or chest pain noted upon examination.
Prescribed intranasal corticosteroid spray for symptomatic relief and advised on environmental allergen control measures.
The patient's symptoms improved with treatment, and education on allergen avoidance was provided upon discharge.
42
Female
Caucasian
ICD Code: R0982
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378495
}
|
The patient has a history of seasonal allergies and occasional asthma exacerbations.
The patient presents with intermittent shortness of breath, palpitations, and occasional dizziness.
ECG shows sinus tachycardia. Chest X-ray reveals no acute abnormalities.
Other specified symptoms and signs involving the circulatory and respiratory systems. The patient presents with intermittent shortness of breath, palpitations, and occasional dizziness, without findings to support other specific diagnoses.
The patient denies any chest pain, cough, or sputum production. No signs of infection or inflammation are noted on examination.
Prescribed albuterol inhaler for symptom relief. Advised on trigger avoidance for asthma exacerbations.
The patient responded well to treatment and was discharged in stable condition with instructions for follow-up with their primary care physician.
45
Female
Caucasian
ICD Code: R0989
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378496
}
|
The patient has a history of occasional gastritis managed with antacids as needed.
The patient presents with a dull, aching pain in the upper abdomen that is constant and worsens after meals. There is no radiation of pain to other areas.
Abdominal ultrasound showed no gallbladder or liver abnormalities.
Upper abdominal pain, unspecified. The patient reports a dull, aching pain in the upper abdomen that worsens after meals, with no radiation of pain to other areas.
Patient denies any history of chest pain, pleuritic pain, or respiratory symptoms. No tenderness on abdominal palpation. Normal bowel sounds noted.
Prescribed antacids for symptomatic relief. Advised dietary modifications and follow-up in two weeks.
Patient's symptoms improved with treatment. Advised to continue antacids as needed and follow up as scheduled.
42
Female
Caucasian
ICD Code: R1010
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378497
}
|
The patient has a history of gastroesophageal reflux disease (GERD) and occasional gastritis.
The patient presents with a burning sensation in the upper abdomen, specifically localized to the epigastric region. The pain is worsened after meals and is not relieved by antacids.
Upper endoscopy revealed mild gastritis with no evidence of peptic ulcers.
Epigastric pain: The patient presents with a burning sensation in the upper abdomen, specifically localized to the epigastric region. The pain is worsened after meals and is not relieved by antacids.
The patient denies any chest pain, shortness of breath, or radiation of pain to other areas. Physical examination shows tenderness upon palpation in the epigastric region.
Prescribed proton pump inhibitors for GERD and advised dietary modifications to alleviate gastritis symptoms.
The patient's epigastric pain improved with treatment, and they were discharged with instructions for follow-up with a gastroenterologist if symptoms persist.
45
Female
Caucasian
ICD Code: R1013
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378498
}
|
The patient has a history of endometriosis and chronic pelvic inflammatory disease.
The patient presents with severe, sharp, and intermittent pain in the pelvic and perineal region. The pain worsens during menstruation and with prolonged sitting.
Pelvic ultrasound shows no abnormalities in the uterus or ovaries. MRI of the pelvis is scheduled to further evaluate the source of pain.
Pelvic and perineal pain: The patient reports severe, sharp, and intermittent pain localized in the pelvic and perineal region. The pain exacerbates during menstruation and prolonged sitting.
Physical examination reveals tenderness upon palpation in the pelvic area. No signs of infection or inflammation are noted. The patient's symptoms are consistent with chronic pelvic pain syndrome.
Prescribed NSAIDs for pain management and referred the patient to a pelvic pain specialist for further evaluation and management.
The patient was discharged in stable condition with pain medications and a follow-up appointment with the pelvic pain specialist in two weeks.
34
Female
Caucasian
ICD Code: R102
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378499
}
|
The patient has a history of irritable bowel syndrome (IBS) and occasional episodes of gastritis.
The patient presents with a dull, aching pain in the lower abdomen. The pain is diffuse and not localized to any specific quadrant. The patient denies any recent trauma or changes in bowel habits.
Laboratory tests including complete blood count (CBC) and comprehensive metabolic panel (CMP) are within normal limits. Abdominal ultrasound shows no significant abnormalities.
Lower abdominal pain, unspecified. Verbatim EHR quote justifying the code: The patient complains of a dull, aching pain in the lower abdomen, which is diffuse and not localized to any specific quadrant.
Physical examination reveals tenderness on palpation in the lower abdominal region. No rebound tenderness or guarding is noted. The patient appears comfortable and in no acute distress.
The patient is advised to take over-the-counter pain relievers as needed for pain management. Follow-up in two weeks is recommended to assess the response to treatment.
The patient's symptoms have improved with conservative management. Discharge instructions include dietary recommendations and potential triggers for IBS exacerbation.
42
Female
Caucasian
ICD Code: R10.30
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378500
}
|
The patient has a history of irritable bowel syndrome (IBS) and occasional constipation.
The patient presents with sharp, localized pain in the right lower quadrant of the abdomen. The pain is aggravated by movement and deep breathing. No rebound tenderness or guarding noted.
CBC and metabolic panel within normal limits. Abdominal ultrasound shows no evidence of appendicitis or other acute pathology.
Right lower quadrant pain: The pain is sharp, localized to the right lower quadrant, worsened by movement, and lacks rebound tenderness or guarding.
Patient denies any recent trauma or unusual physical activity. No fever or gastrointestinal symptoms reported. The pain is consistent with musculoskeletal origin.
Prescribed acetaminophen for pain relief. Advised on heat therapy and gentle stretching exercises for possible muscle strain.
Patient's pain improved with medications and conservative measures. Discharged home with instructions for follow-up if symptoms persist or worsen.
37
Female
Caucasian
ICD Code: R1031
|
{
"dataset_link": "https://huggingface.co/datasets/generative-technologies/synth-ehr-icd10-llama3-format",
"dataset_name": "synth-ehr-icd10-llama3-format",
"id": 378501
}
|
The patient has no history of gastrointestinal disorders or surgeries.
The patient presents with sharp and persistent pain localized to the left lower quadrant of the abdomen. The pain worsens with movement and is not associated with nausea, vomiting, or any urinary symptoms.
Abdominal ultrasound shows mild inflammation in the left lower quadrant without any signs of appendicitis or other acute abdominal conditions.
Left lower quadrant pain: The patient presents with sharp and persistent pain localized to the left lower quadrant of the abdomen. The pain worsens with movement and is not associated with nausea, vomiting, or any urinary symptoms.
The patient reports that the pain started a day ago and has been gradually increasing in intensity. Physical examination reveals tenderness and mild inflammation in the left lower quadrant.
The patient was prescribed ibuprofen for pain management and advised to follow up if symptoms persist or worsen.
The patient's pain improved with medication, and there were no signs of any acute abdominal conditions. The patient was discharged with instructions for a follow-up visit if needed.
35
Female
Caucasian
ICD Code: R1032
|
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