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##### 1. Subjective: **Chief Complaint (CC):** Chronic cough, wheezing, and shortness of breath, especially at night for the past week. **History of Present Illness (HPI):** Mrs. Isabel Garcia is a 45-year-old Hispanic female who presents to the pulmonology clinic with a 1-week history of worsening respiratory sympt...
[doctor]: Hi Mrs. Garcia, how are you doing today? [patient]: Hi, doctor. I'm okay, but I've been having a lot of trouble with my breathing lately. [doctor]: Oh no, I'm sorry to hear that. Can you tell me more about what's been going on? [patient]: Sure. For the past week, I've had this chronic cough, wheezing, and ...
Z930
TRACHEOSTOMY STATUS
**1. Subjective:** **Chief Complaint (CC):** Patient presents with mild to moderate leakage around the gastrostomy site for the past 2 days. **History of Present Illness (HPI):** The patient, a 70-year-old Caucasian female, reports experiencing mild to moderate leakage around her gastrostomy site for the last two day...
[doctor]: Hello, I'm Dr. Anderson. How are you feeling today? [patient]: Hello, Dr. Anderson. I've been better. I'm having some issues with my gastrostomy site. [doctor]: I see. Can you tell me more about what's been going on? [patient]: Sure. For the past two days, I've had some mild to moderate leakage around the ...
Z931
GASTROSTOMY STATUS
### Medical Note #### 1. Subjective: **Chief Complaint (CC):** - Moderate to severe lower left abdominal pain. **History of Present Illness (HPI):** - A 52-year-old African American male, John Doe, presents with moderate to severe lower left abdominal pain that began 3 days ago. Pain is constant and associated with ...
[doctor]: Hi there, how are you doing today? [patient]: Not so good, doc. I've been having some pretty bad pain in my lower left abdomen. [doctor]: I'm sorry to hear that. When did the pain start? [patient]: It started about three days ago. It's been pretty constant since then. [doctor]: Okay, so you've been experi...
Z932
ILEOSTOMY STATUS
**Subjective:** *Chief Complaint (CC):* Severe abdominal pain around the colostomy site. *History of Present Illness (HPI):* A 30-year-old African American female, named Sarah Johnson, presents to the urgent care with severe abdominal pain around her colostomy site that has been ongoing for 2 days. The pain is constan...
[doctor]: Hi, how are you today? [patient]: Not great, honestly. I'm in a lot of pain. [doctor]: I'm sorry to hear that. The medical assistant mentioned you're having severe abdominal pain around your colostomy site. Can you tell me more about it? [patient]: Yes, it started about two days ago. The pain is constant, ...
Z933
COLOSTOMY STATUS
##### **1. Subjective:** **Chief Complaint (CC):** Severe pain and significant leakage around the stoma. **History of Present Illness (HPI):** Mr. Leo Chang, a 60-year-old Asian male, presents to the urgent care center with severe pain around his urostomy site accompanied by significant leakage. The onset of symp...
[doctor]: Hi Mr. Chang, how are you feeling today? [patient]: Not good, doctor. I'm in a lot of pain around my stoma. [doctor]: Hmm, I see. Can you describe the pain for me? [patient]: It's very severe and constant. It started two days ago and hasn't let up at all. [doctor]: Okay, and you mentioned there's leakage ...
Z936
OTHER ARTIFICIAL OPENINGS OF URINARY TRACT STATUS
**1. Subjective:** **Chief Complaint (CC):** Moderate fatigue and occasional dizziness. **History of Present Illness (HPI):** The patient is a 47-year-old Hispanic female with a history of end-stage renal disease (ESRD) and hypothyroidism who presents for chronic disease management. Over the past three weeks, she has...
[doctor]: Hi there, how are you doing today? [patient]: I’m okay, doctor. I’ve been feeling really tired and sometimes a bit dizzy. [doctor]: Hmm, I see. Can you tell me more about these symptoms? How long have you been experiencing them? [patient]: It’s been about three weeks now. The fatigue is moderate, and the d...
Z940
KIDNEY TRANSPLANT STATUS
**Subjective:** **Chief Complaint (CC):** The patient presents for an initial consultation concerning severe heart failure symptoms. **History of Present Illness (HPI):** The patient is a 34-year-old African American female with a history of severe aortic stenosis and congenital heart disease. Over the past 3 months,...
[doctor]: Good morning, I'm Dr. Thompson. How are you feeling today? [patient]: I've been better, Doctor. I'm here because of my heart issues. [doctor]: I see. So, you’re here for an initial consultation concerning severe heart failure symptoms. Can you tell me more about what’s been going on? [patient]: Sure. Over ...
Z941
HEART TRANSPLANT STATUS
**1. Subjective:** **Chief Complaint (CC):** Shortness of breath and rash on forearms. **History of Present Illness (HPI):** The patient, named Mei Lin, is a 60-year-old Asian female, status post lung transplant, who presents with mild to moderate shortness of breath over the past three weeks. She also reports mild f...
[doctor]: Hello, how are you doing today? [patient]: Hello, Doctor. I’ve been better, to be honest. [doctor]: Hmm, I see here you've been experiencing shortness of breath and a rash on your forearms. Could you tell me more about that? [patient]: Yes, for the past three weeks, I've had mild to moderate shortness of b...
Z942
LUNG TRANSPLANT STATUS
##### **1. Subjective:** **Chief Complaint (CC):** Severe abdominal pain and high fever. **History of Present Illness (HPI):** The patient, named Mary Johnson, is a 52-year-old Caucasian female with a history of hepatitis B and hepatocellular carcinoma, who presents to the ER with severe abdominal pain, high fever, c...
[doctor] Good morning, how are you feeling today? [patient] Oh, doctor, I'm in so much pain. My stomach hurts so badly, and I have a high fever. [doctor] I’m sorry to hear that. Could you tell me more about your symptoms? [patient] Yes, the pain started suddenly a few hours ago, and it hasn’t stopped. I also have c...
Z944
LIVER TRANSPLANT STATUS
--- **1. Subjective:** **Chief Complaint (CC):** Moderate skin rash and itching. **History of Present Illness (HPI):** The patient is a 65-year-old Hispanic male with a history of Hodgkin's Lymphoma, currently status post bone marrow transplant, who presents with a moderate skin rash that has been persistent for 1 w...
[doctor]: Hello, how are you doing today? [patient]: Hello, Doctor. I'm not feeling very well. I have this rash that has been bothering me for about a week now. [doctor]: I see. Can you tell me more about this rash? Where is it located, and what does it feel like? [patient]: It's mostly on my arms and chest. It itch...
Z9481
BONE MARROW TRANSPLANT STATUS
**1. Subjective:** **CHIEF COMPLAINT:** Mild fatigue and occasional mild skin rash. **HISTORY OF PRESENT ILLNESS:** The patient is a 42-year-old Caucasian male with a history of acute myeloid leukemia (AML) and chronic graft-versus-host disease (GVHD) status post stem cell transplant. He presents today for a follow-u...
[doctor] Hi there, how are you doing today? [patient] Hi, I'm doing alright, thank you. [doctor] Great to hear. I see you’re here for a follow-up visit. How have you been feeling since your last appointment? [patient] I've been feeling a bit tired lately and I noticed a rash on my forearms. [doctor] Can you tell me...
Z9484
STEM CELLS TRANSPLANT STATUS
**1. Subjective:** **Chief Complaint (CC):** Severe lightheadedness, palpitations, and chest discomfort. **History of Present Illness (HPI):** The patient is a 58-year-old African American male who presents to the community health center with complaints of severe lightheadedness, frequent palpitations, and chest ...
[doctor]: Good morning. [patient]: Morning, doc. [doctor]: How can I help you today? [patient]: I've been feeling really lightheaded and having these weird heart palpitations. My chest feels uncomfortable too. It’s been going on for about two weeks now. [doctor]: Hmm, that sounds concerning. How often are you exper...
Z950
PRESENCE OF CARDIAC PACEMAKER
##### **1. Subjective:** **Chief Complaint (CC):** Moderate chest pain. **History of Present Illness (HPI):** A 60-year-old Asian female, named Mei Lin, presents with a complaint of moderate chest pain. She reports that these episodes last between 5-10 minutes and are typically accompanied by dyspnea and radiating pa...
[Doctor]: Good morning, how are you feeling today? [Patient]: Good morning, doctor. I've been experiencing some moderate chest pain. [Doctor]: I see, can you tell me more about this chest pain? [Patient]: Yes, it's been happening for a while now. The pain lasts between 5 to 10 minutes and usually comes with shortnes...
Z951
PRESENCE OF AORTOCORONARY BYPASS GRAFT
--- **1. Subjective:** **Chief Complaint (CC):** 72-year-old African American female presents with moderate fatigue persisting for 1 month. **History of Present Illness (HPI):** The patient reports experiencing moderate fatigue daily for the past month. The fatigue is associated with shortness of breath and occasio...
[doctor]: Hi, it's good to see you today. I see from your notes that you've been experiencing moderate fatigue for about a month now. Can you tell me a bit more about what's been going on? [patient]: Yes, Doctor. I've been feeling really tired every day for the past month. It's been hard to keep up with my daily activ...
Z952
PRESENCE OF PROSTHETIC HEART VALVE
**1. Subjective:** *Chief Complaint (CC):* - Follow-up visit after coronary angioplasty. *History of Present Illness (HPI):* - The patient is a 78-year-old Hispanic female with a history of coronary artery disease and previous coronary artery bypass grafting (CABG). She presents for a follow-up visit post-coronary an...
[doctor]: Good morning, Mrs. Gonzalez. How are you feeling today? [patient]: Good morning, doctor. I'm feeling alright, thank you. [doctor]: Great to hear. I see you had a coronary angioplasty three months ago due to some chest discomfort. How have you been feeling since then? [patient]: Yes, that's right. The chest...
Z955
PRESENCE OF CORONARY ANGIOPLASTY IMPLANT AND GRAFT
### Subjective **CHIEF COMPLAINT** Sudden worsening of symptoms including shortness of breath and fatigue. **HISTORY OF PRESENT ILLNESS** Mrs. Jones is a 75-year-old African American female with a significant cardiac history who presents to the emergency department with progressively worsening shortness of breath a...
[doctor]: Good morning, Mrs. Jones. How are you feeling today? [patient]: Good morning, doctor. I'm not feeling too well. My shortness of breath and fatigue have been getting worse over the past couple of months. [doctor]: I'm sorry to hear that. Can you describe when you started noticing these symptoms? [patient]: ...
Z9581
PRESENCE OF OTHER CARDIAC IMPLANTS AND GRAFTS
##### **1. Subjective:** **Chief Complaint (CC):** Severe fatigue. **History of Present Illness (HPI):** - **Severity:** Severe. - **Duration:** Past 1 week. - **Associated Symptoms:** Shortness of breath, swelling in the legs. - **Frequency:** Constant. - **Impact on Daily Activities:** Significant. Patient unable ...
[doctor]: Hi, good afternoon. How are you doing today? [patient]: Hi, I'm really tired. I can barely do anything without feeling exhausted. [doctor]: Hmm, I'm sorry to hear that. How long have you been feeling this way? [patient]: It's been about a week now. The fatigue is just so severe. [doctor]: Okay, got it. Ar...
Z95810
PRESENCE OF AUTOMATIC (IMPLANTABLE) CARDIAC DEFIBRILLATOR
### Subjective **CHIEF COMPLAINT** Sudden worsening of symptoms including shortness of breath and fatigue. **HISTORY OF PRESENT ILLNESS** Mrs. Jones is a 75-year-old African American female with a significant cardiac history who presents to the emergency department with progressively worsening shortness of breath a...
[doctor]: Good morning, Mrs. Jones. How are you feeling today? [patient]: Good morning, doctor. I'm not feeling too well. My shortness of breath and fatigue have been getting worse over the past couple of months. [doctor]: I'm sorry to hear that. Can you describe when you started noticing these symptoms? [patient]: ...
Z95818
PRESENCE OF OTHER CARDIAC IMPLANTS AND GRAFTS
#### 1. Subjective: **Chief Complaint (CC):** Blurry vision and ocular discomfort. **History of Present Illness (HPI):** The patient, Mr. James Carter, a 72-year-old African American male, presents for a routine ophthalmology check-up with complaints of blurry vision and occasional floaters over the past two weeks. H...
[doctor] Hello, good to see you today. Can you tell me a little bit about why you're here? [patient] Hi, doctor. I've been having some blurry vision and occasional floaters for the past two weeks. [doctor] Hmm, I see. And when did you first start noticing these symptoms? [patient] It started about two weeks ago. At ...
Z961
PRESENCE OF INTRAOCULAR LENS
##### **1. Subjective:** **Chief Complaint (CC)** Right shoulder pain. **History of Present Illness (HPI)** The patient, Ms. Angela Johnson, is a 55-year-old African American female who presents to the emergency department with moderate right shoulder pain. The pain has been persistent for the past month and occurs s...
[doctor]: Hello, how are you today? [patient]: I'm okay, doctor, but I've been having a lot of trouble with my right shoulder. [doctor]: I see. Can you describe the pain for me? [patient]: It's a moderate pain, and it's been going on for about a month now. It happens several times a week. [doctor]: Hmm, that sounds...
Z96611
PRESENCE OF RIGHT ARTIFICIAL SHOULDER JOINT
##### **1. Subjective:** **Chief Complaint (CC):** Severe left shoulder pain with associated redness, warmth, and occasional fever. **History of Present Illness (HPI):** Maria Gonzalez is a 45-year-old Hispanic female with a past medical history significant for rheumatoid arthritis and total left shoulder arthroplast...
[doctor]: Hi Maria, how are you today? [patient]: Hello, Doctor. To be honest, I'm in a lot of pain. [doctor]: I'm sorry to hear that. I see you're here because of severe left shoulder pain. Can you tell me more about it? [patient]: Yes, my left shoulder has been hurting a lot for the past two months. It’s so bad th...
Z96612
PRESENCE OF LEFT ARTIFICIAL SHOULDER JOINT
**1. Subjective:** **Chief Complaint (CC):** Moderate to severe pain in the right hip area. **History of Present Illness (HPI):** The patient, Mr. James Carter, a 58-year-old African American male, reports experiencing moderate to severe pain in his right hip area. The pain started intermittently one month ago and ha...
[doctor]: Good morning! How are you doing today? [patient]: Good morning, Doctor. I've been better, to be honest. My right hip has been really bothering me. [doctor]: I'm sorry to hear that. Can you describe the pain you're experiencing in your right hip area? [patient]: Sure. The pain is moderate to severe, and it ...
Z96641
PRESENCE OF RIGHT ARTIFICIAL HIP JOINT
##### **1. Subjective** **Chief Complaint (CC):** Moderate intermittent pain in the left hip. **History of Present Illness (HPI):** The patient, Mr. John Smith, a 55-year-old African American male, reports experiencing moderate pain in his left artificial hip joint. The pain typically occurs in the evening, particula...
[doctor] Hi there, how are you doing today? [patient] I'm doing alright, but I've been having some pain in my left hip. [doctor] Hmm, I see. Can you tell me more about the pain? When does it usually occur? [patient] The pain is moderate, and it usually happens in the evening, especially after I've been standing or w...
Z96642
PRESENCE OF LEFT ARTIFICIAL HIP JOINT
##### **1. Subjective:** **Chief Complaint (CC):** Moderate to severe pain in the right knee. **History of Present Illness (HPI):** The patient is a 70-year-old Hispanic female with a history of right knee osteoarthritis and total knee arthroplasty performed 5 years ago who presents with worsening pain in the right kn...
[doctor] Hello, how are you doing today? [patient] Hi, doctor. I'm okay, but my right knee has been giving me a lot of trouble lately. [doctor] I see. Can you tell me more about the pain in your right knee? [patient] Sure, it's been getting worse over the past two months. The pain is pretty bad, moderate to severe, ...
Z96651
PRESENCE OF RIGHT ARTIFICIAL KNEE JOINT
**1. Subjective:** **Chief Complaint (CC):** Intermittent left knee pain with mild swelling and occasional locking. **History of Present Illness (HPI):** The patient is a 27-year-old Asian female presenting for a routine check-up. She reports experiencing moderate discomfort in her left knee for the past 2 weeks. The...
[doctor] Hi there, how are you today? [patient] Hi, I'm alright, thanks. How are you? [doctor] I'm good, thank you. So, what brings you in for your routine check-up today? [patient] Well, I've been having some pain in my left knee for the past two weeks. It's been quite bothersome. [doctor] I see. Can you tell me m...
Z96652
PRESENCE OF LEFT ARTIFICIAL KNEE JOINT
##### **Subjective:** **Chief Complaint (CC)** Mild to moderate knee discomfort post-bilateral knee replacement. **History of Present Illness (HPI)** John Doe is a 70-year-old male with a history of bilateral knee osteoarthritis and hyperlipidemia, who presents for a follow-up visit 6 months post-bilateral knee repla...
[doctor] Hi John, how have you been since your last visit? [patient] Hi, Doctor. I've been okay, but I'm still having some discomfort in my knees. [doctor] Alright, let's talk about that. You're 6 months post-bilateral knee replacement now, correct? [patient] Yes, that's right. [doctor] Can you describe the discomf...
Z96653
PRESENCE OF ARTIFICIAL KNEE JOINT, BILATERAL
##### **1. Subjective:** **Chief Complaint (CC):** Mild discomfort in the knee with an artificial joint. **History of Present Illness (HPI):** The patient is a 68-year-old Caucasian female who presents to the clinic for a follow-up regarding her artificial knee joint. She reports experiencing mild discomfort around t...
[doctor]: Hi there, how are you today? [patient]: I'm doing alright, thank you. I'm here for a follow-up on my knee. [doctor]: Alright, I see that you have some mild discomfort in your knee with an artificial joint. Can you tell me more about it? [patient]: Sure. I've been having mild discomfort around my knee for t...
Z96659
PRESENCE OF UNSPECIFIED ARTIFICIAL KNEE JOINT
##### **1. Subjective:** **Chief Complaint (CC):** Moderate cramping, heavy menstrual bleeding. **History of Present Illness (HPI):** The patient, a 26-year-old Hispanic female named Maria Gonzalez, presents for a follow-up regarding her newly placed intrauterine device (IUD). She has been experiencing moderate cr...
[doctor]: Hi there, how are you feeling today? [patient]: Hi, I'm okay, I guess. [doctor]: So, I see you're here for a follow-up regarding your newly placed intrauterine device. Can you tell me more about how you've been feeling? [patient]: Yeah, I've been having really bad cramping and my periods have been super he...
Z975
PRESENCE OF (INTRAUTERINE) CONTRACEPTIVE DEVICE
**Subjective:** **Chief Complaint (CC):** Mild to moderate back pain. **History of Present Illness (HPI):** The patient, a 54-year-old Caucasian female named Susan Miller, presents for a follow-up visit 2 months post-arthrodesis surgery. She reports ongoing mild to moderate back pain that has persisted since the surg...
[doctor]: Hi there, how are you feeling today? [patient]: Hi, Doctor. I'm doing okay, but I still have some mild to moderate back pain. [doctor]: Hmm, I see. Can you describe the pain for me? How long has it been going on? [patient]: The pain has been there since my arthrodesis surgery two months ago. It fluctuates ...
Z981
ARTHRODESIS STATUS
**1. Subjective:** **Chief Complaint (CC):** Follow-up consultation post-tubal ligation and discussion on potential reversal options. **History of Present Illness (HPI):** The patient, a 40-year-old African-American female, presents for a routine post-tubal ligation check-up and an initial consultation regarding tuba...
[doctor]: Hello, thank you for coming in today. How are you feeling? [patient]: Hi, Doctor. I'm doing okay, just a bit stressed and tired from work. [doctor]: Hmm, I see. Well, today we're here for a follow-up after your tubal ligation and to discuss potential reversal options. How have you been feeling since the pro...
Z9851
TUBAL LIGATION STATUS
##### **1. Subjective:** **Chief Complaint (CC):** - The patient reports moderate fatigue and exertional dyspnea post-coronary angioplasty procedure performed 4 weeks ago. **History of Present Illness (HPI):** - The 72-year-old male presents for an initial consultation after undergoing a coronary angi...
[doctor]: Hello, it's nice to meet you. I see you're here for a follow-up after your coronary angioplasty. How have you been feeling? [patient]: Hi, doctor. Well, I've been feeling quite tired and I get short of breath when I exert myself. It's been like this for about four weeks now. [doctor]: Hmm, I see. Can you te...
Z9861
CORONARY ANGIOPLASTY STATUS
**1. Subjective:** **Chief Complaint (CC):** Moderate gastrointestinal discomfort post-surgery. **History of Present Illness (HPI):** A 50-year-old African American male, named John Smith, presents for a follow-up visit at the community health services clinic. He reports moderate gastrointestinal discomfort over the ...
[doctor] Hi, how are you doing today? [patient] Hello, Doc. I’ve been better, to be honest. [doctor] Hmm, I see. What seems to be the problem? [patient] I’ve been having some moderate gastrointestinal discomfort for the past five days. [doctor] Hmm, can you describe this discomfort a bit more for me? [patient] Sur...
Z9884
BARIATRIC SURGERY STATUS
**1. Subjective:** **Chief Complaint (CC):** Persistent gastrointestinal symptoms. **History of Present Illness (HPI):** Ms. Lee, a 45-year-old Asian female, presents today for an initial consultation regarding persistent gastrointestinal symptoms. She reports experiencing heartburn, regurgitation, and occasional nau...
[doctor] Good morning, Ms. Lee. How are you today? [patient] Good morning, doctor. I've been better, honestly. I've been struggling with some persistent gastrointestinal symptoms. [doctor] I'm sorry to hear that. Can you tell me more about these symptoms? [patient] Sure. I've been having heartburn, regurgitation, an...
Z9889
OTHER SPECIFIED POSTPROCEDURAL STATES
**1. Subjective:** **Chief Complaint (CC):** Persistent gastrointestinal symptoms. **History of Present Illness (HPI):** Ms. Lee, a 45-year-old Asian female, presents today for an initial consultation regarding persistent gastrointestinal symptoms. She reports experiencing heartburn, regurgitation, and occasional nau...
[doctor] Good morning, Ms. Lee. How are you today? [patient] Good morning, doctor. I've been better, honestly. I've been struggling with some persistent gastrointestinal symptoms. [doctor] I'm sorry to hear that. Can you tell me more about these symptoms? [patient] Sure. I've been having heartburn, regurgitation, an...
Z98890
OTHER SPECIFIED POSTPROCEDURAL STATES
##### **1. Subjective:** **Chief Complaint (CC):** Moderate worsening of respiratory symptoms. **History of Present Illness (HPI):** The patient, Mr. John Lee, a 45-year-old Asian male with a known history of severe Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus, and Hypertension, presents for...
[doctor]: Hi there, how are you today? [patient]: Hi, Doctor. I've been better, to be honest. [doctor]: Hmm, I understand. I see you're here for a follow-up. Can you tell me what's been going on? [patient]: Sure. Over the past month, I've noticed my breathing has gotten worse. I feel more short of breath and I'm cou...
Z9911
DEPENDENCE ON RESPIRATOR [VENTILATOR] STATUS
--- **1. Subjective:** **Chief Complaint (CC):** Increased fatigue and frequent urination. **History of Present Illness (HPI):** Ms. Jane Doe is a 55-year-old female presenting for an initial nephrology consultation primarily due to increased fatigue and frequent urination over the past 6 months. She reports the on...
[doctor]: Good morning, Ms. Doe. How are you feeling today? [patient]: Good morning, Doctor. I've been better. My primary care doctor wanted me to see you because of this fatigue and frequent urination I've been experiencing for the past six months. [doctor]: I see. Can you tell me more about these symptoms? When did...
Z992
DEPENDENCE ON RENAL DIALYSIS
##### **1. Subjective:** **Chief Complaint (CC):** Severe breathlessness and frequent night-time awakenings due to breathlessness. **History of Present Illness (HPI):** The patient is a 58-year-old non-native English-speaking Asian male with a history of COPD and obstructive sleep apnea who presents to the urgent car...
[doctor] Good morning. How are you feeling today? [patient] Not so good, doctor. I have been having a lot of trouble breathing. [doctor] I see. Can you explain a bit more about your symptoms? [patient] Yes, for the past six weeks, I have been having severe breathlessness. It gets worse at night, and I wake up freque...
Z9981
DEPENDENCE ON SUPPLEMENTAL OXYGEN