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1,101 | CT Head without contrast: Subarachnoid hemorrhage in bilateral sylvian fissures. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. No acute intracranial hemorrhage. | CT scan of the head results: There is bleeding around the brain surface, particularly in the grooves on both sides. There are aging-related changes in the brain's white matter from reduced blood flow to small vessels over time. There is no bleeding in the brain. | Neurology | Radiology Report | high |
1,102 | Procedure: EGD with biopsy. Pt 40 y/o F. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes upper endoscopy with small tissue samples taken for a 40-year-old woman. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | Gastroenterology | Procedure Note | high |
1,103 | 81 y/o M presenting to ED with severe epigastric pain radiating to back, N/V x 6hrs. Vitals: BP 138/82, HR 108, RR 20, T 100.4F. Lipase 1800 (H). CT abdomen: peripancreatic fat stranding, no necrosis. Dx: Acute pancreatitis. NPO, aggressive IVF, IV morphine, IV pantoprazole. Admit medicine. | A 81-year-old man came to the emergency room with severe upper belly pain shooting to the back with nausea and vomiting for 6 hours. Vital signs: blood pressure normal, heart rate fast, mild fever. Pancreas enzyme very high. CT scan showed severe pancreas inflammation but no dead tissue. Diagnosis: severe inflammation ... | Emergency Medicine | Clinical Note | high |
1,104 | CT Head without contrast: No mass effect. Chronic lacunar infarcts in bilateral basal ganglia. No acute intracranial hemorrhage. | CT scan of the head results: There are no tumors or masses pushing on the brain. There are signs of small old strokes in the deep parts of the brain. There is no bleeding in the brain. | Neurology | Radiology Report | high |
1,105 | 77 y/o M presenting to ED with acute onset pleuritic CP, SOB, R calf swelling x 3 days. Vitals: BP 132/88, HR 112, RR 24, O2 91% on RA. D-dimer elevated. CTA chest: bilateral PE with RV strain. US R LE: popliteal DVT. Dx: Bilateral PE with DVT. Heparin drip started. Consider catheter-directed thrombolysis given RV stra... | A 77-year-old man came to the emergency room with sudden chest pain that worsens with breathing, shortness of breath, and right calf swelling for 3 days. Vital signs: blood pressure normal, heart rate fast, breathing rapid, oxygen low at 91%. A blood clot screening test was positive. CT scan confirmed blood clots in bo... | Emergency Medicine | Clinical Note | high |
1,106 | 64 y/o M with PMH of cirrhosis, DM1, HFpEF, SLE, admitted for cellulitis R lower extremity. Leg was red, swollen, and warm. IV antibiotics started. Managed per protocol with improvement. Elevate R leg above heart level when resting. D/C on ondansetron 4mg Q8H PRN N/V, metoprolol succinate 50mg daily, Humalog per SSI, c... | A 64-year-old man with a history of liver scarring [cirrhosis], type 1 diabetes, heart failure with stiff heart muscle, and lupus was admitted for a skin infection in the right leg. Leg was red, swollen, and warm. IV antibiotics started. They were treated according to standard guidelines and improved. When resting, pro... | Infectious Disease | Discharge Summary | high |
1,107 | Rx: Tab warfarin 5mg daily. Tab gabapentin 300mg TID. Adv: DASH diet, daily BP monitoring. F/U INR in 3 days. | Your medicines: (1) warfarin 5mg once daily [blood thinner — requires regular INR blood tests]. (2) gabapentin 300mg three times daily [nerve pain medicine — may cause drowsiness]. Advice: follow the DASH diet (rich in fruits, vegetables, lean protein, low in salt) and check blood pressure at home daily. Come back in 3... | Neurology | Prescription | medium |
1,108 | US Abdomen: GB sludge, no stones. Left kidney 8cm, cortical thinning consistent with CKD. CBD 5mm, not dilated. Right kidney 10.5cm, no hydronephrosis. Ascites moderate amount. Simple renal cysts bilaterally. | Abdominal ultrasound results: The gallbladder contains thickened bile [sludge] but no stones. Left kidney is small with thin outer layer, consistent with chronic kidney disease. The bile duct is normal size [not blocked]. Right kidney is normal size with no blockage. There is a moderate amount of fluid in the belly [as... | Gastroenterology | Radiology Report | high |
1,109 | 51 y/o M presenting to ED with sudden onset R-sided weakness, facial droop, slurred speech x 45 min. Vitals: BP 188/102, HR 88, RR 16, O2 97%. CT Head: no hemorrhage. CTA: L MCA occlusion. NIHSS 14. Dx: Acute ischemic stroke, L MCA territory. tPA administered (within 3hr window). Thrombectomy team activated. Admit stro... | A 51-year-old man came to the emergency room with sudden right-sided weakness, face drooping on one side, and slurred speech for 45 minutes. Vital signs: blood pressure very high, heart rate normal, breathing normal, oxygen normal. CT scan ruled out bleeding. Blood vessel scan showed a blocked artery on the left side o... | Emergency Medicine | Clinical Note | high |
1,110 | Rx: Tab Xarelto 20mg daily with dinner. Tab levothyroxine 75mcg daily on empty stomach. prednisone taper. Tab amlodipine 10mg daily. Tab tramadol 50mg Q6H PRN pain. Adv: low potassium diet Adv: SMBG BID, diabetic diet. F/U 1 week with CBC, CMP. | Your medicines: (1) Xarelto 20mg once daily with dinner [blood thinner]. (2) levothyroxine 75mcg on empty stomach 30 min before breakfast [thyroid medicine]. (3) prednisone steroid — dose gradually decreases as directed [do not stop suddenly]. (4) amlodipine 10mg once daily [blood pressure medicine]. (5) tramadol 50mg ... | Cardiology | Prescription | high |
1,111 | Rx: Tab atorvastatin 40mg QHS. Tab Xarelto 20mg daily with dinner. Tab ondansetron 4mg Q8H PRN N/V. Adv: low salt diet, fluid restriction 1.5L/day. F/U 1 week with CBC, CMP. | Your medicines: (1) atorvastatin 40mg at bedtime [cholesterol medicine]. (2) Xarelto 20mg once daily with dinner [blood thinner]. (3) ondansetron (Zofran) 4mg every 8 hours as needed [anti-nausea medicine]. Advice: eat less salt and limit your total fluid intake to about 6 cups per day. Come back in 1 week for blood te... | Cardiology | Prescription | medium |
1,112 | Escitalopram 10mg AM; effect builds over weeks; avoid abrupt alcohol use. | Antidepressant taken in the morning; benefits increase over several weeks; limit alcohol. | Psychiatry | Medication Instruction | high |
1,113 | PATH: Shave bx: actinic keratosis, suggest sunscreen and dermatology follow-up. | Pathology results in plain language: Sun-damaged spot on skin — precancerous change. Protect skin from sun and follow with skin doctor. | Dermatology | Pathology Report | high |
1,114 | CXR PA: Osseous structures intact. Pacemaker leads in appropriate position. Compression fracture T12. Moderate right pleural effusion. Right middle lobe atelectasis. | Chest X-ray results: The bones look normal with no fractures. The pacemaker wires are in the correct position. There is a compression fracture [collapsed bone] in the lower spine at T12. There is a moderate amount of fluid around the right lung. Part of the right lung has partially collapsed [atelectasis], possibly fro... | Pulmonology | Radiology Report | high |
1,115 | Rx: Tab gabapentin 300mg TID. Tab lisinopril 10mg daily. Humalog per SSI. Lantus 20U QHS. Tab ASA 81mg daily. Adv: elevate affected limb, compression stockings. F/U 6 weeks with LFTs. | Your medicines: (1) gabapentin 300mg three times daily [nerve pain medicine — may cause drowsiness]. (2) lisinopril 10mg once daily [blood pressure medicine that also protects kidneys]. (3) Humalog insulin before meals as directed [fast-acting insulin]. (4) Lantus insulin 20 units at bedtime [long-acting insulin]. (5) ... | Cardiology | Prescription | high |
1,116 | 26 y/o F presenting to ED with severe epigastric pain radiating to back, N/V x 6hrs. Vitals: BP 138/82, HR 108, RR 20, T 100.4F. Lipase 1800 (H). CT abdomen: peripancreatic fat stranding, no necrosis. Dx: Acute pancreatitis. NPO, aggressive IVF, IV morphine, IV pantoprazole. Admit medicine. | A 26-year-old woman came to the emergency room with severe upper belly pain shooting to the back with nausea and vomiting for 6 hours. Vital signs: blood pressure normal, heart rate fast, mild fever. Pancreas enzyme very high. CT scan showed severe pancreas inflammation but no dead tissue. Diagnosis: severe inflammatio... | Emergency Medicine | Clinical Note | high |
1,117 | 89 y/o F with PMH of ICD in situ, anemia, admitted for acute CHF exacerbation. BNP elevated. CXR showed pulmonary edema. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on pantoprazole 40mg AC breakfast, azithromycin 500mg day 1 then 250mg x 4 days. F/U pulmonology in 2 we... | A 89-year-old woman with a history of implanted heart defibrillator, and low blood count [anemia] was admitted for worsening heart failure with fluid buildup. BNP elevated. Chest X-ray showed pulmonary edema. They were treated according to standard guidelines and improved. Use the breathing exercise device every hour w... | Cardiology | Discharge Summary | high |
1,118 | 63 y/o M with PMH of CKD Stage 4, HFpEF, depression, SLE, admitted for GI bleeding. Hemoglobin dropped. Required blood transfusion. Managed per protocol with improvement. Compression stockings when ambulating. D/C on lisinopril 20mg daily, Spiriva 18mcg daily, amoxicillin 500mg TID x 10 days, Dulcolax 10mg QHS PRN. F/U... | A 63-year-old man with a history of advanced kidney disease, heart failure with stiff heart muscle, depression, and lupus was admitted for bleeding in the digestive tract. Blood count dropped. Required blood transfusion. They were treated according to standard guidelines and improved. Wear compression stockings on your... | Gastroenterology | Discharge Summary | high |
1,119 | 69 y/o M with PMH of s/p THR, depression, gout, s/p TKR, admitted for appendicitis. CT confirmed. Taken to OR for laparoscopic appendectomy. Managed per protocol with improvement. Daily weights, 1.5L fluid restriction, low sodium diet. D/C on Augmentin 875/125 BID x 7 days, acetaminophen 650mg Q6H PRN. F/U pulmonology ... | A 69-year-old man with a history of prior hip replacement, depression, gout, and prior knee replacement was admitted for inflammation of the appendix. CT confirmed. Taken to OR for laparoscopic appendectomy. They were treated according to standard guidelines and improved. Weigh yourself every morning before eating. Lim... | General Surgery | Discharge Summary | high |
1,120 | Doxycycline 100mg BID x 14 days with water; stay upright 30 min; avoid sun. | Take this antibiotic twice daily for 14 days with plenty of water, stay upright after doses, and use sun protection. | Infectious Disease | Medication Instruction | high |
1,121 | Rx: Tab hydroxychloroquine 200mg BID. Tab azithromycin 500mg day 1 then 250mg x 4 days. prednisone taper. Humalog per SSI. Avoid grapefruit juice. F/U 2 weeks with INR. | Your medicines: (1) hydroxychloroquine 200mg twice daily [immune-modulating medicine — eye exams needed]. (2) azithromycin: 500mg on day 1, then 250mg for the next 4 days [antibiotic]. (3) prednisone steroid — dose gradually decreases as directed [do not stop suddenly]. (4) Humalog insulin before meals as directed [fas... | Rheumatology | Prescription | high |
1,122 | 29 y/o M presenting to ED with severe epigastric pain radiating to back, N/V x 6hrs. Vitals: BP 138/82, HR 108, RR 20, T 100.4F. Lipase 1800 (H). CT abdomen: peripancreatic fat stranding, no necrosis. Dx: Acute pancreatitis. NPO, aggressive IVF, IV morphine, IV pantoprazole. Admit medicine. | A 29-year-old man came to the emergency room with severe upper belly pain shooting to the back with nausea and vomiting for 6 hours. Vital signs: blood pressure normal, heart rate fast, mild fever. Pancreas enzyme very high. CT scan showed severe pancreas inflammation but no dead tissue. Diagnosis: severe inflammation ... | Emergency Medicine | Clinical Note | high |
1,123 | PATH: Skin excision: melanoma in situ, Breslow not applicable, peripheral margins clear. | Pathology results in plain language: Early melanoma confined to the top skin layer, removed with clear edges. | Dermatology | Pathology Report | high |
1,124 | 48 y/o M with PMH of CKD Stage 4, HLD, Parkinson's disease, admitted for STEMI. ECG showed ST elevation. Troponin markedly elevated. Managed per protocol with improvement. Elevate R leg above heart level when resting. D/C on lisinopril 10mg daily, acetaminophen 650mg Q6H PRN, prednisone taper. F/U endocrine in 1 week. | A 48-year-old man with a history of advanced kidney disease, high cholesterol, and Parkinson's disease was admitted for a serious heart attack requiring emergency treatment. ECG showed ST elevation. Troponin markedly elevated. They were treated according to standard guidelines and improved. When resting, prop your righ... | Cardiology | Discharge Summary | high |
1,125 | Delivery Note: G?P? at 40+0 weeks. Primary low-transverse C-section. Live male infant. APGAR 8/9. EBL within expected limits. Mother stable. | Birth summary: pregnancy reached about 40+0 weeks gestation. The baby was delivered by C-section through a low horizontal cut on the uterus. The newborn is a healthy male. APGAR scores were 8/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
1,126 | 52 y/o M presenting to ED with hematemesis x 2 episodes, dark tarry stools x 2 days. Vitals: BP 92/58, HR 122, RR 22, O2 96%. Hgb 6.8 (baseline 13). Type and crossmatch sent. 2 units pRBC transfused. EGD: bleeding duodenal ulcer, treated with epinephrine injection + clips. Dx: Upper GI bleed secondary to duodenal ulcer... | A 52-year-old man came to the emergency room with vomiting blood twice and having dark, tarry stools for 2 days. Vital signs: blood pressure dangerously low, heart rate very fast (signs of significant blood loss). Blood count dropped severely (6.8, was 13). Two units of blood transfused. Camera test of stomach found a ... | Emergency Medicine | Clinical Note | high |
1,127 | Rx: Tab Augmentin 875/125 BID x 7 days. Tab metformin 500mg BID. Tab losartan 50mg daily. Tab Eliquis 5mg BID. Tab azithromycin 500mg day 1 then 250mg x 4 days. Adv: low potassium diet. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT. | Your medicines: (1) Augmentin 875mg twice daily for 7 days [antibiotic]. (2) metformin 500mg twice daily with meals [blood sugar medicine]. (3) losartan 50mg once daily [blood pressure medicine]. (4) Eliquis 5mg twice daily [blood thinner]. (5) azithromycin: 500mg on day 1, then 250mg for the next 4 days [antibiotic]. ... | Infectious Disease | Prescription | high |
1,128 | Procedure: Colonoscopy with polypectomy. Pt 33 y/o M. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes colon exam with removal of polyps for a 33-year-old man. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | Gastroenterology | Procedure Note | high |
1,129 | CXR PA: Pacemaker leads in appropriate position. Right middle lobe atelectasis. Sternotomy wires intact. | Chest X-ray results: The pacemaker wires are in the correct position. Part of the right lung has partially collapsed [atelectasis], possibly from mucus plugging. The wires from prior heart surgery are intact. | Pulmonology | Radiology Report | high |
1,130 | 57 y/o M with PMH of seizure disorder on Keppra, CKD Stage 3, admitted for cellulitis R lower extremity. Leg was red, swollen, and warm. IV antibiotics started. Managed per protocol with improvement. Strict NPO after midnight before procedure. D/C on metformin 500mg BID, Dulcolax 10mg QHS PRN, gabapentin 300mg TID, Spi... | A 57-year-old man with a history of seizure disorder [on Keppra], and moderate kidney disease was admitted for a skin infection in the right leg. Leg was red, swollen, and warm. IV antibiotics started. They were treated according to standard guidelines and improved. Do not eat or drink anything after midnight the night... | Infectious Disease | Discharge Summary | high |
1,131 | 78 y/o F presenting to ED with severe epigastric pain radiating to back, N/V x 6hrs. Vitals: BP 138/82, HR 108, RR 20, T 100.4F. Lipase 1800 (H). CT abdomen: peripancreatic fat stranding, no necrosis. Dx: Acute pancreatitis. NPO, aggressive IVF, IV morphine, IV pantoprazole. Admit medicine. | A 78-year-old woman came to the emergency room with severe upper belly pain shooting to the back with nausea and vomiting for 6 hours. Vital signs: blood pressure normal, heart rate fast, mild fever. Pancreas enzyme very high. CT scan showed severe pancreas inflammation but no dead tissue. Diagnosis: severe inflammatio... | Emergency Medicine | Clinical Note | high |
1,132 | Procedure: Laparoscopic cholecystectomy. Pt 87 y/o M. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes minimally invasive gallbladder removal for a 87-year-old man. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | General Surgery | Procedure Note | high |
1,133 | LFTs: AST 79 (H), ALT 81 (H), ALP 214, T.Bili 1.7 (H), Albumin 4.9. | Your liver blood test results: Liver enzymes (AST 79, ALT 81) are moderately elevated, indicating liver irritation (normal is under 40). Bilirubin is mildly elevated at 1.7. Albumin is normal at 4.9. | Gastroenterology | Lab Result | high |
1,134 | HbA1c: 9.4% (H). FBS: 134 mg/dL (H). | Your diabetes blood test results: HbA1c is 9.4%, which is high, meaning your blood sugar has been poorly controlled over the past 3 months (target is under 7%). Fasting blood sugar was 134, which is high (normal is 70-100). Your diabetes treatment needs to be changed. This level increases risk of complications. | Endocrinology | Lab Result | high |
1,135 | CXR PA: Left lower lobe consolidation. Pacemaker leads in appropriate position. Bilateral pleural effusions. Increased interstitial markings suggesting pulmonary edema. | Chest X-ray results: There is an area in the lower left lung that appears infected. The pacemaker wires are in the correct position. There is fluid collecting around both lungs. There are signs of extra fluid in the lung tissue, suggesting the heart may not be pumping efficiently [pulmonary edema]. | Pulmonology | Radiology Report | high |
1,136 | MRI Lumbar Spine: C5-C6 disc herniation with cord compression. L5-S1 disc desiccation with mild bulge. No compression fracture. Conus medullaris at L1, normal. | MRI of the lower back results: At C5-C6 in the neck, a disc has pushed out and is pressing on the spinal cord — this is significant. At the L5-S1 level, the disc is dried out [worn] with a slight bulge, but not causing significant pressure. No bones are broken or collapsed. The spinal cord ends at a normal level. | Orthopedics | Radiology Report | high |
1,137 | Procedure: PCI with DES to LAD. Pt 86 y/o M. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes heart catheter procedure to place a stent in a heart artery for a 86-year-old man. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | Cardiology | Procedure Note | high |
1,138 | Insulin lispro: count carbs and match units per sliding scale; treat lows per rule. | Fast-acting insulin dosing follows carbohydrate counting and your prescribed sliding scale; treat low blood sugar using your education handout. | Endocrinology | Medication Instruction | medium |
1,139 | Rx: Spiriva 18mcg daily. Tab metformin 500mg BID. Tab rosuvastatin 10mg QHS. Tab entresto 49/51mg BID. Adv: low salt low sugar diet, regular exercise. F/U 1 week with CBC, CMP. | Your medicines: (1) Spiriva inhaler once daily [long-acting lung medicine]. (2) metformin 500mg twice daily with meals [blood sugar medicine]. (3) rosuvastatin 10mg at bedtime [cholesterol medicine]. (4) Entresto 49/51mg twice daily [heart failure medicine]. Advice: eat less salt and sugar, and exercise at least 30 min... | Cardiology | Prescription | high |
1,140 | Rx: Tab acetaminophen 650mg Q6H PRN. Tab calcium + vitamin D 600/400 daily. Tab gabapentin 300mg TID. Tab metoprolol succinate 50mg daily. Adv: low salt low sugar diet, regular exercise Avoid grapefruit juice. F/U 2 weeks with INR. | Your medicines: (1) Tylenol (acetaminophen) 650mg every 6 hours as needed [do not exceed 3000mg/day]. (2) calcium plus vitamin D once daily [bone strengthening]. (3) gabapentin 300mg three times daily [nerve pain medicine — may cause drowsiness]. (4) metoprolol 50mg once daily [heart rate and blood pressure medicine]. ... | General | Prescription | high |
1,141 | PATH: LN bx: reactive lymphoid hyperplasia, no evidence of lymphoma. | Pathology results in plain language: Lymph node sample shows reactive swelling from infection/inflammation, not lymphoma. | Hematology | Pathology Report | high |
1,142 | 70 y/o F with PMH of HFpEF, asthma, admitted for DKA. Blood sugar >500. pH 7.1. Anion gap elevated. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on montelukast 10mg QHS, clopidogrel 75mg daily, Eliquis 5mg BID. F/U oncology in 1 week. | A 70-year-old woman with a history of heart failure with stiff heart muscle, and asthma was admitted for diabetic ketoacidosis [dangerously high blood sugar with acid buildup]. Blood sugar >500. blood became dangerously acidic. Anion gap elevated. They were treated according to standard guidelines and improved. Be care... | Endocrinology | Discharge Summary | high |
1,143 | Procedure: Laparoscopic appendectomy. Pt 87 y/o M. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes keyhole surgery to remove the appendix for a 87-year-old man. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | General Surgery | Procedure Note | high |
1,144 | Insulin lispro: count carbs and match units per sliding scale; treat lows per rule. | Fast-acting insulin dosing follows carbohydrate counting and your prescribed sliding scale; treat low blood sugar using your education handout. | Endocrinology | Medication Instruction | medium |
1,145 | Rx: Spiriva 18mcg daily. Tab ASA 81mg daily. Avoid grapefruit juice Adv: DASH diet, daily BP monitoring. F/U 2 weeks. | Your medicines: (1) Spiriva inhaler once daily [long-acting lung medicine]. (2) baby aspirin 81mg once daily [prevents blood clots]. Do not drink grapefruit juice as it interferes with this medication Advice: follow the DASH diet (rich in fruits, vegetables, lean protein, low in salt) and check blood pressure at home d... | Cardiology | Prescription | medium |
1,146 | 70 y/o F with PMH of OA, CHF, admitted for fall with hip fracture. X-ray confirmed femoral neck fracture. Orthopedics consulted. Managed per protocol with improvement. Strict I&O, daily weights. D/C on azithromycin 500mg day 1 then 250mg x 4 days, metoprolol succinate 50mg daily, amoxicillin 500mg TID x 10 days. F/U su... | A 70-year-old woman with a history of arthritis [osteoarthritis], and heart failure was admitted for broken hip after a fall. X-ray confirmed femoral neck fracture. Orthopedics consulted. They were treated according to standard guidelines and improved. Track how much you drink and urinate. Weigh yourself every morning.... | Orthopedics | Discharge Summary | high |
1,147 | MRI Lumbar Spine: No compression fracture. Conus medullaris at L1, normal. Central canal stenosis at L3-L4. Multilevel degenerative disc disease. | MRI of the lower back results: No bones are broken or collapsed. The spinal cord ends at a normal level. The spinal canal is narrowed at L3-L4, which may be pressing on the nerves. Multiple discs in the spine are showing wear and aging. | Orthopedics | Radiology Report | high |
1,148 | US Abdomen: CBD 12mm, dilated. GB wall thickening with stones, positive Murphy's sign. Liver 18cm, diffusely echogenic consistent with hepatic steatosis. GB sludge, no stones. Pancreas unremarkable. | Abdominal ultrasound results: The bile duct is wider than normal [dilated], which may indicate a blockage. The gallbladder wall is thickened and gallstones are present — pressing on the gallbladder area caused pain [positive Murphy's sign], suggesting infection. The liver is slightly enlarged and appears brighter than ... | Gastroenterology | Radiology Report | high |
1,149 | CT Head without contrast: No acute intracranial hemorrhage. Mild generalized cerebral atrophy appropriate for age. Paranasal sinuses clear. No midline shift. Acute ischemic infarct in R MCA territory. | CT scan of the head results: There is no bleeding in the brain. There is mild brain shrinkage, which is normal for your age. The sinuses are clear with no infection. The brain is centered normally. There is a new stroke affecting the right side of the brain, in the area supplied by the middle cerebral artery. | Neurology | Radiology Report | high |
1,150 | 44 y/o F with PMH of s/p TKR, HTN, DVT/PE on warfarin, RA on MTX, hypothyroidism, admitted for HHS. Blood sugar >800. Severe dehydration. Managed per protocol with improvement. Head injury precautions x 48hrs. D/C on pregabalin 75mg BID, gabapentin 300mg TID, ibuprofen 400mg Q6H PRN with food, Lantus 20U QHS. F/U INR c... | A 44-year-old woman with a history of prior knee replacement, high blood pressure, blood clots [on blood thinner warfarin], rheumatoid arthritis [on immune-suppressing medicine], and underactive thyroid was admitted for hyperosmolar hyperglycemic state [extremely high blood sugar]. Blood sugar >800. Severe dehydration.... | Endocrinology | Discharge Summary | high |
1,151 | 78 y/o M with PMH of ICD in situ, COPD, CHF, HLD, DM1, admitted for DKA. Blood sugar >500. pH 7.1. Anion gap elevated. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on potassium chloride 20mEq daily, losartan 50mg daily, hydroxychloroquine 200mg BID, atorvastatin 80mg QHS. F/U P... | A 78-year-old man with a history of implanted heart defibrillator, chronic lung disease, heart failure, high cholesterol, and type 1 diabetes was admitted for diabetic ketoacidosis [dangerously high blood sugar with acid buildup]. Blood sugar >500. blood became dangerously acidic. Anion gap elevated. They were treated ... | Endocrinology | Discharge Summary | high |
1,152 | Methotrexate 15mg weekly on fixed weekday only; folic acid except MTX day; avoid alcohol. | Take methotrexate only once per week on the same day — never daily. Take folic acid as directed. Avoid alcohol. | Rheumatology | Medication Instruction | medium |
1,153 | Procedure: TURP for BPH. Pt 62 y/o F. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes scope surgery to trim enlarged prostate tissue for a 62-year-old woman. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | Urology | Procedure Note | high |
1,154 | Escitalopram 10mg AM; effect builds over weeks; avoid abrupt alcohol use. | Antidepressant taken in the morning; benefits increase over several weeks; limit alcohol. | Psychiatry | Medication Instruction | low |
1,155 | PATH: LN bx: reactive lymphoid hyperplasia, no evidence of lymphoma. | Pathology results in plain language: Lymph node sample shows reactive swelling from infection/inflammation, not lymphoma. | Hematology | Pathology Report | high |
1,156 | HbA1c: 13.1% (H). FBS: 78 mg/dL (N). | Your diabetes blood test results: HbA1c is 13.1%, which is very high, meaning blood sugar has been dangerously uncontrolled (target is under 7%). Fasting blood sugar was 78, which is normal (normal is 70-100). Urgent medication adjustment needed. Very high risk of diabetes complications at this level. | Endocrinology | Lab Result | high |
1,157 | 27 y/o F with PMH of cirrhosis, PPM in situ, h/o CVA, admitted for PE. CTA positive for PE. Heparin started. Managed per protocol with improvement. Seizure precautions, do not drive x 6 months. D/C on lisinopril 20mg daily, gabapentin 300mg TID, amlodipine 10mg daily. F/U neurology in 2 weeks. | A 27-year-old woman with a history of liver scarring [cirrhosis], implanted pacemaker, and history of stroke was admitted for a blood clot in the lungs [pulmonary embolism]. CT scan confirmed a blood clot in the lungs. Heparin started. They were treated according to standard guidelines and improved. Take seizure safety... | Pulmonology | Discharge Summary | high |
1,158 | CXR PA: Sternotomy wires intact. No cardiomegaly. NG tube tip in stomach. Port-a-cath in appropriate position. | Chest X-ray results: The wires from prior heart surgery are intact. The heart is a normal size. The feeding/drainage tube tip is correctly positioned in the stomach. The implanted medication port is in the correct position. | Pulmonology | Radiology Report | high |
1,159 | Amiodarone load per protocol then maintenance; monitor thyroid and liver tests. | Heart rhythm medicine starts with a supervised loading phase then a lower daily dose. Blood tests monitor thyroid and liver. | Cardiology | Medication Instruction | high |
1,160 | 69 y/o M presenting to ED with substernal CP radiating to L arm x 1hr, diaphoresis. Vitals: BP 165/95, HR 92, RR 18, O2 98%. ECG: ST elevation V1-V4. Troponin 2.1 (H). Dx: STEMI. Cath lab activated. ASA 325mg, Plavix 600mg, heparin bolus. Emergent PCI. | A 69-year-old man came to the emergency room with crushing chest pain spreading to the left arm for 1 hour with heavy sweating. Vital signs: blood pressure elevated, heart rate slightly fast, breathing normal, oxygen normal. Heart test (ECG) showed a heart attack pattern. Blood test confirmed heart muscle damage. Diagn... | Emergency Medicine | Clinical Note | high |
1,161 | Lipid panel: TC 143, LDL 138, HDL 56, TG 435. | Your cholesterol results: Total cholesterol is 143. LDL (bad cholesterol) is high at 138 (goal under 100). HDL (good cholesterol) is good at 56. Triglycerides are very high at 435 (normal under 150) — increases risk of pancreatitis. | Cardiology | Lab Result | high |
1,162 | 69 y/o F presenting to ED with acute onset pleuritic CP, SOB, R calf swelling x 3 days. Vitals: BP 132/88, HR 112, RR 24, O2 91% on RA. D-dimer elevated. CTA chest: bilateral PE with RV strain. US R LE: popliteal DVT. Dx: Bilateral PE with DVT. Heparin drip started. Consider catheter-directed thrombolysis given RV stra... | A 69-year-old woman came to the emergency room with sudden chest pain that worsens with breathing, shortness of breath, and right calf swelling for 3 days. Vital signs: blood pressure normal, heart rate fast, breathing rapid, oxygen low at 91%. A blood clot screening test was positive. CT scan confirmed blood clots in ... | Emergency Medicine | Clinical Note | high |
1,163 | PATH: Colon: tubular adenoma with low-grade dysplasia, completely excised. | Pathology results in plain language: Colon polyp is a benign growth with mild abnormal cells, fully removed. | Oncology | Pathology Report | high |
1,164 | CT Head without contrast: Mild generalized cerebral atrophy appropriate for age. Subarachnoid hemorrhage in bilateral sylvian fissures. Acute ischemic infarct in R MCA territory. | CT scan of the head results: There is mild brain shrinkage, which is normal for your age. There is bleeding around the brain surface, particularly in the grooves on both sides. There is a new stroke affecting the right side of the brain, in the area supplied by the middle cerebral artery. | Neurology | Radiology Report | high |
1,165 | Lipid panel: TC 240, LDL 144, HDL 25, TG 383. | Your cholesterol results: Total cholesterol is 240. LDL (bad cholesterol) is high at 144 (goal under 100). HDL (good cholesterol) is too low at 25 (should be above 40 for men, 50 for women) — this is a risk factor for heart disease. Triglycerides are very high at 383 (normal under 150) — increases risk of pancreatitis. | Cardiology | Lab Result | high |
1,166 | Levetiracetam 500mg BID; do not stop suddenly; report mood changes. | Anti-seizure medicine twice daily; taper only with clinician guidance; watch for mood side effects. | Neurology | Medication Instruction | low |
1,167 | Rx: Tab Dulcolax 10mg QHS PRN. Tab ondansetron 4mg Q8H PRN N/V. Adv: smoking cessation, pulmonary rehab Adv: SMBG BID, diabetic diet. F/U INR in 3 days. | Your medicines: (1) Dulcolax 10mg at bedtime as needed [for constipation]. (2) ondansetron (Zofran) 4mg every 8 hours as needed [anti-nausea medicine]. Advice: stop smoking (ask about nicotine patches or gum) and attend lung rehabilitation program Advice: check your blood sugar twice daily and follow a diabetes-friendl... | General | Prescription | medium |
1,168 | BMP: Na 129 (L), K 2.8 (L), BUN 61, Cr 4.8 (H), Glucose 262. | Your blood chemistry results: Sodium is low at 129 (normal 136-145), meaning too much water in your body. Potassium is low at 2.8 — may cause muscle weakness and heart rhythm issues. Creatinine is elevated at 4.8 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 262 (high). | Nephrology | Lab Result | high |
1,169 | CXR PA: Moderate right pleural effusion. Clear lung fields bilaterally. Right middle lobe atelectasis. Right-sided pneumothorax. Osseous structures intact. | Chest X-ray results: There is a moderate amount of fluid around the right lung. Both lungs look clear with no problems. Part of the right lung has partially collapsed [atelectasis], possibly from mucus plugging. The right lung has partially collapsed due to air leaking into the chest cavity [pneumothorax]. The bones lo... | Pulmonology | Radiology Report | high |
1,170 | LFTs: AST 308 (H), ALT 483 (H), ALP 67, T.Bili 6.6 (H), Albumin 2.5. | Your liver blood test results: Liver enzymes (AST 308, ALT 483) are severely elevated, indicating significant liver damage (normal is under 40). Bilirubin is high at 6.6 (normal under 1.2) — may cause yellowing of skin and eyes [jaundice]. Albumin is low at 2.5 (normal 3.5-5.5), suggesting the liver is struggling to ma... | Gastroenterology | Lab Result | high |
1,171 | Rx: Tab escitalopram 10mg daily. Tab atorvastatin 40mg QHS. Tab levothyroxine 75mcg daily on empty stomach. Tab acetaminophen 650mg Q6H PRN. Tab ciprofloxacin 500mg BID x 5 days. Avoid NSAIDs Adv: low salt low sugar diet, regular exercise. F/U 1 week with wound check. | Your medicines: (1) escitalopram 10mg once daily [antidepressant/anxiety medicine]. (2) atorvastatin 40mg at bedtime [cholesterol medicine]. (3) levothyroxine 75mcg on empty stomach 30 min before breakfast [thyroid medicine]. (4) Tylenol (acetaminophen) 650mg every 6 hours as needed [do not exceed 3000mg/day]. (5) cipr... | Cardiology | Prescription | high |
1,172 | CBC: WBC 19.5 (H), Hgb 10.8 (L), Plt 51 (L). | Your blood count results: White blood cells are 19.5 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is low at 10.8, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 51, which is low — your blood may not clot properly, increasing bl... | Hematology | Lab Result | high |
1,173 | CXR PA: Moderate right pleural effusion. Compression fracture T12. Left lower lobe consolidation. Right middle lobe atelectasis. | Chest X-ray results: There is a moderate amount of fluid around the right lung. There is a compression fracture [collapsed bone] in the lower spine at T12. There is an area in the lower left lung that appears infected. Part of the right lung has partially collapsed [atelectasis], possibly from mucus plugging. | Pulmonology | Radiology Report | high |
1,174 | 64 y/o F with PMH of HLD, hypothyroidism, SLE, anemia, ICD in situ, admitted for pyelonephritis. UA showed infection. Flank pain and fever. IV antibiotics started. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on ondansetron 4mg Q8H PRN N/V, prednisone taper. F/U hematology in 2 weeks. | A 64-year-old woman with a history of high cholesterol, underactive thyroid, lupus, low blood count [anemia], and implanted heart defibrillator was admitted for a serious kidney infection. Urine test confirmed infection. Flank pain and fever. IV antibiotics started. They were treated according to standard guidelines an... | Urology | Discharge Summary | high |
1,175 | 54 y/o M with PMH of RA on MTX, asthma, PAD, HLD, A-fib, admitted for atrial fibrillation with RVR. HR 150s. Diltiazem drip started for rate control. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on lisinopril 10mg daily, spironolactone 25mg daily, Xarelto 20mg daily wit... | A 54-year-old man with a history of rheumatoid arthritis [on immune-suppressing medicine], asthma, poor blood flow in the legs [peripheral artery disease], high cholesterol, and irregular heartbeat [atrial fibrillation] was admitted for irregular heartbeat with dangerously fast rate. HR 150s. Diltiazem drip started for... | Cardiology | Discharge Summary | high |
1,176 | Delivery Note: G?P? at 37+3 weeks. SVD. Live female infant. APGAR 8/9. EBL within expected limits. Mother stable. | Birth summary: pregnancy reached about 37+3 weeks gestation. The baby was delivered by normal vaginal delivery. The newborn is a healthy female. APGAR scores were 8/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
1,177 | 25 y/o M with PMH of GERD, CAD, depression, A-fib, admitted for cholecystitis. US showed gallbladder wall thickening and stones. Surgery consulted. Managed per protocol with improvement. Strict NPO after midnight before procedure. D/C on calcium + vitamin D 600/400 daily, metformin 500mg BID, lisinopril 10mg daily. F/U... | A 25-year-old man with a history of acid reflux, coronary artery disease [heart artery blockages], depression, and irregular heartbeat [atrial fibrillation] was admitted for gallbladder infection/inflammation. US showed gallbladder wall thickening and stones. Surgery consulted. They were treated according to standard g... | General Surgery | Discharge Summary | high |
1,178 | 51 y/o M with PMH of s/p TKR, ICD in situ, A-fib, anxiety, admitted for appendicitis. CT confirmed. Taken to OR for laparoscopic appendectomy. Managed per protocol with improvement. Strict I&O, daily weights. D/C on carvedilol 12.5mg BID, prednisone taper, pantoprazole 40mg AC breakfast. F/U wound care in 3 days. | A 51-year-old man with a history of prior knee replacement, implanted heart defibrillator, irregular heartbeat [atrial fibrillation], and anxiety was admitted for inflammation of the appendix. CT confirmed. Taken to OR for laparoscopic appendectomy. They were treated according to standard guidelines and improved. Track... | General Surgery | Discharge Summary | high |
1,179 | Rx: Tab lisinopril 10mg daily. Tab entresto 49/51mg BID. Tab potassium chloride 20mEq daily. Avoid grapefruit juice Adv: low salt diet, fluid restriction 1.5L/day. F/U INR in 3 days. | Your medicines: (1) lisinopril 10mg once daily [blood pressure medicine that also protects kidneys]. (2) Entresto 49/51mg twice daily [heart failure medicine]. (3) potassium supplement 20mEq once daily [replaces potassium lost from water pills]. Do not drink grapefruit juice as it interferes with this medication Advice... | Cardiology | Prescription | medium |
1,180 | CT Head without contrast: No midline shift. Chronic lacunar infarcts in bilateral basal ganglia. 4cm right subdural hematoma with 5mm midline shift. Acute ischemic infarct in R MCA territory. No mass effect. | CT scan of the head results: The brain is centered normally. There are signs of small old strokes in the deep parts of the brain. There is a significant blood collection (4cm) on the right side between the brain and skull, pushing the brain 5mm to the left — this is serious. There is a new stroke affecting the right si... | Neurology | Radiology Report | high |
1,181 | 33 y/o F with PMH of Parkinson's disease, OA, depression, PPM in situ, admitted for sepsis secondary to cellulitis. Blood cultures drawn. IV antibiotics started emergently. Managed per protocol with improvement. Strict NPO after midnight before procedure. D/C on clopidogrel 75mg daily, prednisone taper, metoprolol 25mg... | A 33-year-old woman with a history of Parkinson's disease, arthritis [osteoarthritis], depression, and implanted pacemaker was admitted for a serious blood infection from a skin infection. Blood cultures drawn. IV antibiotics started emergently. They were treated according to standard guidelines and improved. Do not ea... | Infectious Disease | Discharge Summary | high |
1,182 | PATH: Skin excision: melanoma in situ, Breslow not applicable, peripheral margins clear. | Pathology results in plain language: Early melanoma confined to the top skin layer, removed with clear edges. | Dermatology | Pathology Report | high |
1,183 | 58 y/o M with PMH of osteoporosis, asthma, h/o CVA, hypothyroidism, admitted for sepsis secondary to cellulitis. Blood cultures drawn. IV antibiotics started emergently. Managed per protocol with improvement. BRAT diet x 48hrs, advance as tolerated. D/C on Spiriva 18mcg daily, potassium chloride 20mEq daily, furosemide... | A 58-year-old man with a history of weak bones [osteoporosis], asthma, history of stroke, and underactive thyroid was admitted for a serious blood infection from a skin infection. Blood cultures drawn. IV antibiotics started emergently. They were treated according to standard guidelines and improved. Eat bland food for... | Infectious Disease | Discharge Summary | high |
1,184 | CXR PA: Right-sided pneumothorax. NG tube tip in stomach. Small left pleural effusion. | Chest X-ray results: The right lung has partially collapsed due to air leaking into the chest cavity [pneumothorax]. The feeding/drainage tube tip is correctly positioned in the stomach. There is a small amount of fluid around the left lung. | Pulmonology | Radiology Report | high |
1,185 | PATH: Shave bx: actinic keratosis, suggest sunscreen and dermatology follow-up. | Pathology results in plain language: Sun-damaged spot on skin — precancerous change. Protect skin from sun and follow with skin doctor. | Dermatology | Pathology Report | high |
1,186 | Rx: Tab metformin 1000mg BID. Humalog per SSI. Tab furosemide 40mg BID. Adv: low salt diet, fluid restriction 1.5L/day. F/U 2 weeks with INR. | Your medicines: (1) metformin 1000mg twice daily with meals [blood sugar medicine]. (2) Humalog insulin before meals as directed [fast-acting insulin]. (3) furosemide (Lasix) 40mg twice daily [water pill]. Advice: eat less salt and limit your total fluid intake to about 6 cups per day. Come back in 2 weeks for a blood ... | Endocrinology | Prescription | medium |
1,187 | CXR PA: Widened mediastinum. No pneumothorax. Right-sided pneumothorax. NG tube tip in stomach. Right lower lobe consolidation. | Chest X-ray results: The space between the lungs appears wider than normal, which needs further evaluation. There is no collapsed lung. The right lung has partially collapsed due to air leaking into the chest cavity [pneumothorax]. The feeding/drainage tube tip is correctly positioned in the stomach. There is an area i... | Pulmonology | Radiology Report | high |
1,188 | 76 y/o M presenting to ED with fall from standing, R hip pain, unable to bear weight. Vitals: BP 142/78, HR 88, RR 16, O2 97%. X-ray pelvis: displaced R femoral neck fracture. Pre-op labs WNL. ECG: NSR. Dx: R femoral neck fracture. Pain management with IV morphine. NPO for OR. Ortho consult for hemiarthroplasty vs ORIF... | A 76-year-old man came to the emergency room with fell from standing, severe right hip pain, unable to put weight on the right leg. Vital signs: blood pressure slightly high (pain), heart rate normal, breathing normal, oxygen normal. X-ray showed a broken hip bone (displaced femoral neck fracture) on the right side. Pr... | Emergency Medicine | Clinical Note | high |
1,189 | CXR PA: Right lower lobe consolidation. Increased interstitial markings suggesting pulmonary edema. Bilateral hilar lymphadenopathy. Hyperinflated lungs consistent with COPD. Pacemaker leads in appropriate position. | Chest X-ray results: There is an area in the lower right lung that appears infected, suggesting pneumonia. There are signs of extra fluid in the lung tissue, suggesting the heart may not be pumping efficiently [pulmonary edema]. There are enlarged lymph nodes at the root of both lungs, which needs further evaluation. T... | Pulmonology | Radiology Report | high |
1,190 | US Abdomen: Left kidney 8cm, cortical thinning consistent with CKD. CBD 12mm, dilated. Spleen 11cm, normal. Simple renal cysts bilaterally. Right kidney 10.5cm, no hydronephrosis. | Abdominal ultrasound results: Left kidney is small with thin outer layer, consistent with chronic kidney disease. The bile duct is wider than normal [dilated], which may indicate a blockage. The spleen is a normal size. Both kidneys have harmless fluid-filled cysts. Right kidney is normal size with no blockage. | Gastroenterology | Radiology Report | high |
1,191 | LFTs: AST 115 (H), ALT 445 (H), ALP 284, T.Bili 6.1 (H), Albumin 2.1. | Your liver blood test results: Liver enzymes (AST 115, ALT 445) are severely elevated, indicating significant liver damage (normal is under 40). Bilirubin is high at 6.1 (normal under 1.2) — may cause yellowing of skin and eyes [jaundice]. Albumin is low at 2.1 (normal 3.5-5.5), suggesting the liver is struggling to ma... | Gastroenterology | Lab Result | high |
1,192 | PATH: Skin excision: melanoma in situ, Breslow not applicable, peripheral margins clear. | Pathology results in plain language: Early melanoma confined to the top skin layer, removed with clear edges. | Dermatology | Pathology Report | high |
1,193 | 42 y/o F with PMH of seizure disorder on Keppra, HLD, admitted for STEMI. ECG showed ST elevation. Troponin markedly elevated. Managed per protocol with improvement. Diabetic diet, SMBG BID. D/C on tramadol 50mg Q6H PRN pain, rosuvastatin 10mg QHS, potassium chloride 20mEq daily, albuterol MDI 2 puffs Q4-6H PRN. F/U su... | A 42-year-old woman with a history of seizure disorder [on Keppra], and high cholesterol was admitted for a serious heart attack requiring emergency treatment. ECG showed ST elevation. Troponin markedly elevated. They were treated according to standard guidelines and improved. Follow a diabetes-friendly diet (limit swe... | Cardiology | Discharge Summary | high |
1,194 | 74 y/o F with PMH of osteoporosis, ESRD on HD, hypothyroidism, admitted for syncope. Cardiac workup and neurologic evaluation performed. Managed per protocol with improvement. Daily weights, 1.5L fluid restriction, low sodium diet. D/C on lisinopril 20mg daily, tramadol 50mg Q6H PRN pain, furosemide 40mg daily, ondanse... | A 74-year-old woman with a history of weak bones [osteoporosis], kidney failure requiring dialysis, and underactive thyroid was admitted for fainting [loss of consciousness]. Cardiac workup and neurologic evaluation performed. They were treated according to standard guidelines and improved. Weigh yourself every morning... | Cardiology | Discharge Summary | high |
1,195 | 74 y/o F with PMH of A-fib, HLD, admitted for DKA. Blood sugar >500. pH 7.1. Anion gap elevated. Managed per protocol with improvement. Strict NPO after midnight before procedure. D/C on timolol 0.5% OU BID, amlodipine 10mg daily, empagliflozin 10mg daily, glipizide 5mg BID AC. F/U nephrology in 5 days. | A 74-year-old woman with a history of irregular heartbeat [atrial fibrillation], and high cholesterol was admitted for diabetic ketoacidosis [dangerously high blood sugar with acid buildup]. Blood sugar >500. blood became dangerously acidic. Anion gap elevated. They were treated according to standard guidelines and imp... | Endocrinology | Discharge Summary | high |
1,196 | CT Head without contrast: Chronic lacunar infarcts in bilateral basal ganglia. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. Mild generalized cerebral atrophy appropriate for age. Paranasal sinuses clear. | CT scan of the head results: There are signs of small old strokes in the deep parts of the brain. There are aging-related changes in the brain's white matter from reduced blood flow to small vessels over time. There is mild brain shrinkage, which is normal for your age. The sinuses are clear with no infection. | Neurology | Radiology Report | high |
1,197 | PATH: LN bx: reactive lymphoid hyperplasia, no evidence of lymphoma. | Pathology results in plain language: Lymph node sample shows reactive swelling from infection/inflammation, not lymphoma. | Hematology | Pathology Report | high |
1,198 | LFTs: AST 44 (H), ALT 184 (H), ALP 149, T.Bili 7.2 (H), Albumin 3.6. | Your liver blood test results: Liver enzymes (AST 44, ALT 184) are moderately elevated, indicating liver irritation (normal is under 40). Bilirubin is high at 7.2 (normal under 1.2) — may cause yellowing of skin and eyes [jaundice]. Albumin is normal at 3.6. | Gastroenterology | Lab Result | high |
1,199 | Rx: Tab atorvastatin 40mg QHS. Tab ondansetron 4mg Q8H PRN N/V. Adv: low potassium diet. F/U PCP in 1 week for BP recheck. | Your medicines: (1) atorvastatin 40mg at bedtime [cholesterol medicine]. (2) ondansetron (Zofran) 4mg every 8 hours as needed [anti-nausea medicine]. Advice: avoid high-potassium foods like bananas, oranges, potatoes, and tomatoes. See your primary care doctor in 1 week to recheck blood pressure. | Cardiology | Prescription | medium |
1,200 | Delivery Note: G?P? at 39+1 weeks. Primary low-transverse C-section. Live male infant. APGAR 7/9. EBL within expected limits. Mother stable. | Birth summary: pregnancy reached about 39+1 weeks gestation. The baby was delivered by C-section through a low horizontal cut on the uterus. The newborn is a healthy male. APGAR scores were 7/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
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