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1,201
Rx: Tab gabapentin 300mg TID. Tab Dulcolax 10mg QHS PRN. Adv: fall precautions, home safety evaluation. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT.
Your medicines: (1) gabapentin 300mg three times daily [nerve pain medicine — may cause drowsiness]. (2) Dulcolax 10mg at bedtime as needed [for constipation]. Advice: take steps to prevent falls — remove loose rugs, install grab bars, use night lights. Come back in 2 weeks with blood tests for: fasting blood sugar [FB...
Neurology
Prescription
medium
1,202
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
1,203
Procedure: Colonoscopy with polypectomy. Pt 68 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 colon exam with removal of polyps for a 68-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
1,204
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
1,205
Thyroid panel: TSH 5.45 (H), Free T4 1.2.
Your thyroid test results: TSH is elevated at 5.45 (normal 0.4-4.5), meaning your thyroid is underactive [hypothyroidism]. Free T4 is borderline — confirming the thyroid is not producing enough hormone.
Endocrinology
Lab Result
high
1,206
69 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 69-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
1,207
Rx: Tab calcium + vitamin D 600/400 daily. Tab furosemide 40mg BID. Do not stop abruptly, taper as directed Adv: wound care with daily dressing changes. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT.
Your medicines: (1) calcium plus vitamin D once daily [bone strengthening]. (2) furosemide (Lasix) 40mg twice daily [water pill]. Do not suddenly stop this medicine — your doctor will gradually reduce the dose if needed Advice: change the wound dressing once daily — clean with saline, apply ointment, cover with fresh b...
Cardiology
Prescription
medium
1,208
64 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 64-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
1,209
MRI Lumbar Spine: L4-L5 disc herniation with moderate bilateral foraminal stenosis. Facet joint hypertrophy at L4-L5. C5-C6 disc herniation with cord compression. Conus medullaris at L1, normal.
MRI of the lower back results: At the L4-L5 level, a disc has pushed outward [herniated] and is narrowing the nerve tunnels on both sides. The small joints in the spine at L4-L5 are enlarged from arthritis. At C5-C6 in the neck, a disc has pushed out and is pressing on the spinal cord — this is significant. The spinal ...
Orthopedics
Radiology Report
high
1,210
LFTs: AST 272 (H), ALT 61 (H), ALP 81, T.Bili 4.2 (H), Albumin 4.5.
Your liver blood test results: Liver enzymes (AST 272, ALT 61) are mildly elevated (normal is under 40). Bilirubin is high at 4.2 (normal under 1.2) — may cause yellowing of skin and eyes [jaundice]. Albumin is normal at 4.5.
Gastroenterology
Lab Result
high
1,211
Thyroid panel: TSH 2.84 (N), Free T4 1.1.
Your thyroid test results: TSH is normal at 2.84. Free T4 is normal — your thyroid function is balanced.
Endocrinology
Lab Result
medium
1,212
CXR PA: Mild cardiomegaly. ET tube 3cm above carina. Bilateral pleural effusions.
Chest X-ray results: The heart is slightly larger than normal. The breathing tube is in good position. There is fluid collecting around both lungs.
Pulmonology
Radiology Report
high
1,213
61 y/o M with PMH of s/p CABG, s/p THR, CKD Stage 4, cirrhosis, admitted for PE. CTA positive for PE. Heparin started. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on rosuvastatin 10mg QHS, lisinopril 20mg daily, ibuprofen 400mg Q6H PRN with food. F/U hematology in 2 weeks.
A 61-year-old man with a history of prior heart bypass surgery, prior hip replacement, advanced kidney disease, and liver scarring [cirrhosis] 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...
Pulmonology
Discharge Summary
high
1,214
US Abdomen: CBD 5mm, not dilated. GB wall thickening with stones, positive Murphy's sign. Pancreas unremarkable.
Abdominal ultrasound results: The bile duct is normal size [not blocked]. The gallbladder wall is thickened and gallstones are present — pressing on the gallbladder area caused pain [positive Murphy's sign], suggesting infection. The pancreas looks normal.
Gastroenterology
Radiology Report
high
1,215
BMP: Na 150 (H), K 2.7 (L), BUN 66, Cr 2.6 (H), Glucose 235.
Your blood chemistry results: Sodium is high at 150, meaning you may be dehydrated. Potassium is low at 2.7 — may cause muscle weakness and heart rhythm issues. Creatinine is elevated at 2.6 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 235 (high).
Nephrology
Lab Result
high
1,216
US Abdomen: Spleen 11cm, normal. Spleen 16cm, splenomegaly. CBD 12mm, dilated.
Abdominal ultrasound results: The spleen is a normal size. The spleen is enlarged [splenomegaly]. The bile duct is wider than normal [dilated], which may indicate a blockage.
Gastroenterology
Radiology Report
high
1,217
Rx: Tab warfarin 5mg daily. Tab glipizide 5mg BID AC. Tab entresto 49/51mg BID. Tab furosemide 40mg daily. Adv: low salt low sugar diet, regular exercise Adv: elevate affected limb, compression stockings. F/U INR in 3 days.
Your medicines: (1) warfarin 5mg once daily [blood thinner — requires regular INR blood tests]. (2) glipizide 5mg twice daily before meals [helps release insulin]. (3) Entresto 49/51mg twice daily [heart failure medicine]. (4) furosemide (Lasix) 40mg once daily [water pill to remove extra fluid]. Advice: eat less salt ...
Cardiology
Prescription
high
1,218
Delivery Note: G?P? at 37+3 weeks. Primary low-transverse C-section. Live female infant. APGAR 9/9. EBL within expected limits. Mother stable.
Birth summary: pregnancy reached about 37+3 weeks gestation. The baby was delivered by C-section through a low horizontal cut on the uterus. The newborn is a healthy female. APGAR scores were 9/9. Bleeding was normal. Mother did well after delivery.
Obstetrics
Delivery Note
high
1,219
Procedure: ORIF L distal radius. Pt 40 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 surgery to fix a wrist fracture with plate and screws for a 40-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.
Orthopedics
Procedure Note
high
1,220
Rx: Humalog per SSI. Tab ibuprofen 400mg Q6H PRN with food. Tab glipizide 5mg BID AC. Tab furosemide 40mg daily. Tab levothyroxine 75mcg daily on empty stomach. Adv: smoking cessation, pulmonary rehab. F/U 4 weeks with TSH, Free T4.
Your medicines: (1) Humalog insulin before meals as directed [fast-acting insulin]. (2) ibuprofen 400mg every 6 hours as needed with food [anti-inflammatory pain reliever]. (3) glipizide 5mg twice daily before meals [helps release insulin]. (4) furosemide (Lasix) 40mg once daily [water pill to remove extra fluid]. (5) ...
Endocrinology
Prescription
high
1,221
Rx: Tab empagliflozin 10mg daily. Lantus 20U QHS. Tab ferrous sulfate 325mg BID. Adv: weight bearing exercise, calcium/vit D supplementation. F/U 2 weeks with INR.
Your medicines: (1) empagliflozin 10mg once daily [blood sugar medicine that also protects heart and kidneys]. (2) Lantus insulin 20 units at bedtime [long-acting insulin]. (3) iron supplement 325mg twice daily [for low blood count — take with vitamin C]. Advice: do weight-bearing exercises (walking, light weights) and...
Endocrinology
Prescription
medium
1,222
31 y/o M with PMH of PPM in situ, h/o CVA, DM2, gout, admitted for cellulitis R lower extremity. Leg was red, swollen, and warm. IV antibiotics started. Managed per protocol with improvement. Strict I&O, daily weights. D/C on Augmentin 875/125 BID x 7 days, omeprazole 20mg AC breakfast, metformin 500mg BID. F/U PCP in ...
A 31-year-old man with a history of implanted pacemaker, history of stroke, type 2 diabetes, and gout 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. Track how much you drink and urinate. Weigh y...
Infectious Disease
Discharge Summary
high
1,223
MRI Lumbar Spine: L4-L5 disc herniation with moderate bilateral foraminal stenosis. Central canal stenosis at L3-L4.
MRI of the lower back results: At the L4-L5 level, a disc has pushed outward [herniated] and is narrowing the nerve tunnels on both sides. The spinal canal is narrowed at L3-L4, which may be pressing on the nerves.
Orthopedics
Radiology Report
high
1,224
Rx: Tab acetaminophen 650mg Q6H PRN. Tab warfarin 5mg daily. Adv: low salt low sugar diet, regular exercise Avoid NSAIDs. F/U 1 week with wound check.
Your medicines: (1) Tylenol (acetaminophen) 650mg every 6 hours as needed [do not exceed 3000mg/day]. (2) warfarin 5mg once daily [blood thinner — requires regular INR blood tests]. Advice: eat less salt and sugar, and exercise at least 30 minutes most days Do not take anti-inflammatory pain medicines like ibuprofen (A...
Hematology
Prescription
medium
1,225
BMP: Na 137 (N), K 4.0 (N), BUN 28, Cr 4.9 (H), Glucose 216.
Your blood chemistry results: Sodium is normal at 137. Potassium is normal at 4.0. Creatinine is elevated at 4.9 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 216 (high).
Nephrology
Lab Result
high
1,226
US Abdomen: Ascites moderate amount. CBD 5mm, not dilated. Liver 18cm, diffusely echogenic consistent with hepatic steatosis.
Abdominal ultrasound results: There is a moderate amount of fluid in the belly [ascites]. The bile duct is normal size [not blocked]. The liver is slightly enlarged and appears brighter than normal, indicating fatty liver disease.
Gastroenterology
Radiology Report
high
1,227
BMP: Na 137 (N), K 5.5 (H), BUN 42, Cr 3.7 (H), Glucose 351.
Your blood chemistry results: Sodium is normal at 137. Potassium is high at 5.5 — needs monitoring. Creatinine is elevated at 3.7 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 351 (high).
Nephrology
Lab Result
high
1,228
34 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 34-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
1,229
27 y/o M with PMH of CKD Stage 4, cirrhosis, anxiety, HLD, admitted for cellulitis R lower extremity. Leg was red, swollen, and warm. IV antibiotics started. Managed per protocol with improvement. Seizure precautions, do not drive x 6 months. D/C on atorvastatin 80mg QHS, escitalopram 10mg daily, amoxicillin 500mg TID ...
A 27-year-old man with a history of advanced kidney disease, liver scarring [cirrhosis], anxiety, and high cholesterol 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. Take seizure safety measures...
Infectious Disease
Discharge Summary
high
1,230
Rx: Tab metformin 500mg BID. Tab amlodipine 5mg daily. Avoid NSAIDs Adv: smoking cessation, pulmonary rehab. F/U 1 week with CBC, CMP.
Your medicines: (1) metformin 500mg twice daily with meals [blood sugar medicine]. (2) amlodipine 5mg once daily [blood pressure medicine]. Do not take anti-inflammatory pain medicines like ibuprofen (Advil) or naproxen (Aleve) as they can harm your kidneys Advice: stop smoking (ask about nicotine patches or gum) and a...
Cardiology
Prescription
medium
1,231
HbA1c: 11.0% (H). FBS: 361 mg/dL (H).
Your diabetes blood test results: HbA1c is 11.0%, which is very high, meaning blood sugar has been dangerously uncontrolled (target is under 7%). Fasting blood sugar was 361, which is high (normal is 70-100). Urgent medication adjustment needed. Very high risk of diabetes complications at this level.
Endocrinology
Lab Result
high
1,232
Delivery Note: G?P? at 37+3 weeks. SVD. Live male infant. APGAR 7/9. 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 male. APGAR scores were 7/9. Bleeding was normal. Mother did well after delivery.
Obstetrics
Delivery Note
high
1,233
80 y/o M with PMH of cirrhosis, ESRD on HD, obesity (BMI 38), admitted for chest pain r/o ACS. Serial troponins and cardiac monitoring performed. Managed per protocol with improvement. Seizure precautions, do not drive x 6 months. D/C on amoxicillin 500mg TID x 10 days, warfarin 5mg daily, escitalopram 10mg daily, albu...
A 80-year-old man with a history of liver scarring [cirrhosis], kidney failure requiring dialysis, and obesity was admitted for chest pain being evaluated for a possible heart attack. Serial troponins and cardiac monitoring performed. They were treated according to standard guidelines and improved. Take seizure safety ...
Cardiology
Discharge Summary
high
1,234
84 y/o F presenting to ED with acute onset SOB, unable to speak in full sentences. Vitals: BP 168/92, HR 118, RR 28, O2 85% on RA. CXR: bilateral pleural effusions, pulmonary edema. BNP 2400. Dx: Acute decompensated CHF. IV furosemide 80mg, BiPAP, nitroglycerin drip. Admit CCU.
A 84-year-old woman came to the emergency room with sudden severe difficulty breathing, unable to finish sentences. Vital signs: blood pressure high, heart rate very fast, breathing very rapid, oxygen dangerously low at 85%. Chest X-ray showed fluid in both lungs. Heart failure blood test very high. Diagnosis: severe h...
Emergency Medicine
Clinical Note
high
1,235
BMP: Na 123 (L), K 5.2 (H), BUN 81, Cr 3.2 (H), Glucose 164.
Your blood chemistry results: Sodium is low at 123 (normal 136-145), meaning too much water in your body. Potassium is high at 5.2 — needs monitoring. Creatinine is elevated at 3.2 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 164 (high).
Nephrology
Lab Result
high
1,236
49 y/o M with PMH of s/p CABG, h/o CVA, CKD Stage 4, BPH, admitted for DKA. Blood sugar >500. pH 7.1. Anion gap elevated. Managed per protocol with improvement. Diabetic diet, SMBG BID. D/C on methotrexate 15mg weekly, amoxicillin 500mg TID x 10 days, calcium + vitamin D 600/400 daily. F/U endocrine in 1 week.
A 49-year-old man with a history of prior heart bypass surgery, history of stroke, advanced kidney disease, and enlarged prostate 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...
Endocrinology
Discharge Summary
high
1,237
MRI Lumbar Spine: Multilevel degenerative disc disease. L5-S1 disc desiccation with mild bulge. L4-L5 disc herniation with moderate bilateral foraminal stenosis. No compression fracture.
MRI of the lower back results: Multiple discs in the spine are showing wear and aging. At the L5-S1 level, the disc is dried out [worn] with a slight bulge, but not causing significant pressure. At the L4-L5 level, a disc has pushed outward [herniated] and is narrowing the nerve tunnels on both sides. No bones are brok...
Orthopedics
Radiology Report
high
1,238
Rx: Tab omeprazole 20mg AC breakfast. Tab hydroxychloroquine 200mg BID. Adv: SMBG BID, diabetic diet. F/U PCP in 1 week for BP recheck.
Your medicines: (1) omeprazole 20mg before breakfast [acid-reducing medicine]. (2) hydroxychloroquine 200mg twice daily [immune-modulating medicine — eye exams needed]. Advice: check your blood sugar twice daily and follow a diabetes-friendly diet. See your primary care doctor in 1 week to recheck blood pressure.
Gastroenterology
Prescription
medium
1,239
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
1,240
70 y/o F with PMH of depression, h/o CVA, admitted for NSTEMI. Troponin elevated confirming heart muscle damage. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on ciprofloxacin 500mg BID x 5 days, Humalog per SSI, tramadol 50mg Q6H PRN pain, losartan 50mg daily. F/U wound care in...
A 70-year-old woman with a history of depression, and history of stroke was admitted for a type of heart attack (non-ST elevation myocardial infarction). A blood test (troponin) was elevated confirming heart muscle damage. They were treated according to standard guidelines and improved. Write down your blood sugar read...
Cardiology
Discharge Summary
high
1,241
67 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 67-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
1,242
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
1,243
81 y/o F with PMH of A-fib, CHF, OSA on CPAP, obesity (BMI 38), gout, admitted for sepsis secondary to cellulitis. Blood cultures drawn. IV antibiotics started emergently. Managed per protocol with improvement. Seizure precautions, do not drive x 6 months. D/C on warfarin 5mg daily, losartan 50mg daily, entresto 49/51m...
A 81-year-old woman with a history of irregular heartbeat [atrial fibrillation], heart failure, sleep apnea [uses a breathing machine at night], obesity, and gout was admitted for a serious blood infection from a skin infection. Blood cultures drawn. IV antibiotics started emergently. They were treated according to sta...
Infectious Disease
Discharge Summary
high
1,244
CT Head without contrast: 4cm right subdural hematoma with 5mm midline shift. Mild generalized cerebral atrophy appropriate for age. Paranasal sinuses clear. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. Chronic lacunar infarcts in bilateral basal ganglia.
CT scan of the head results: 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 mild brain shrinkage, which is normal for your age. The sinuses are clear with no infection. There are aging-related changes in the brai...
Neurology
Radiology Report
high
1,245
CT Head without contrast: Chronic lacunar infarcts in bilateral basal ganglia. Acute ischemic infarct in R MCA territory. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. Subarachnoid hemorrhage in bilateral sylvian fissures.
CT scan of the head results: There are signs of small old strokes in the deep parts of the brain. There is a new stroke affecting the right side of the brain, in the area supplied by the middle cerebral artery. There are aging-related changes in the brain's white matter from reduced blood flow to small vessels over tim...
Neurology
Radiology Report
high
1,246
Lipid panel: TC 162, LDL 180, HDL 71, TG 85.
Your cholesterol results: Total cholesterol is 162. LDL (bad cholesterol) is very high at 180 (goal under 100), significantly increasing heart disease risk. HDL (good cholesterol) is good at 71. Triglycerides are normal at 85.
Cardiology
Lab Result
high
1,247
Rx: Tab lisinopril 20mg daily. Tab losartan 50mg daily. Tab timolol 0.5% OU BID. Tab furosemide 40mg BID. albuterol MDI 2 puffs Q4-6H PRN. Adv: low salt diet, fluid restriction 1.5L/day Adv: DASH diet, daily BP monitoring. F/U INR in 3 days.
Your medicines: (1) lisinopril 20mg once daily [blood pressure medicine]. (2) losartan 50mg once daily [blood pressure medicine]. (3) timolol eye drops in both eyes twice daily [lowers eye pressure for glaucoma]. (4) furosemide (Lasix) 40mg twice daily [water pill]. (5) albuterol inhaler 2 puffs every 4-6 hours as need...
Cardiology
Prescription
high
1,248
77 y/o F 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 77-year-old woman 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. ...
Emergency Medicine
Clinical Note
high
1,249
Rx: Tab acetaminophen 650mg Q6H PRN. Tab methotrexate 15mg weekly. Tab sertraline 50mg daily. Adv: fall precautions, home safety evaluation Adv: low potassium diet. F/U 1 week with wound check.
Your medicines: (1) Tylenol (acetaminophen) 650mg every 6 hours as needed [do not exceed 3000mg/day]. (2) methotrexate 15mg once weekly [immune-suppressing medicine for arthritis — requires monitoring]. (3) sertraline 50mg once daily [antidepressant/anxiety medicine]. Advice: take steps to prevent falls — remove loose ...
Psychiatry
Prescription
medium
1,250
HbA1c: 12.4% (H). FBS: 167 mg/dL (H).
Your diabetes blood test results: HbA1c is 12.4%, which is very high, meaning blood sugar has been dangerously uncontrolled (target is under 7%). Fasting blood sugar was 167, which is high (normal is 70-100). Urgent medication adjustment needed. Very high risk of diabetes complications at this level.
Endocrinology
Lab Result
high
1,251
50 y/o F with PMH of osteoporosis, DVT/PE on warfarin, ICD in situ, gout, s/p THR, admitted for chest pain r/o ACS. Serial troponins and cardiac monitoring performed. Managed per protocol with improvement. Head injury precautions x 48hrs. D/C on ciprofloxacin 500mg BID x 5 days, Dulcolax 10mg QHS PRN. F/U surgery in 10...
A 50-year-old woman with a history of weak bones [osteoporosis], blood clots [on blood thinner warfarin], implanted heart defibrillator, gout, and prior hip replacement was admitted for chest pain being evaluated for a possible heart attack. Serial troponins and cardiac monitoring performed. They were treated according...
Cardiology
Discharge Summary
high
1,252
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
1,253
CXR PA: Mild cardiomegaly. ET tube 3cm above carina. Hyperinflated lungs consistent with COPD. Left lower lobe consolidation.
Chest X-ray results: The heart is slightly larger than normal. The breathing tube is in good position. The lungs appear over-inflated, which is typical of chronic lung disease [COPD/emphysema]. There is an area in the lower left lung that appears infected.
Pulmonology
Radiology Report
high
1,254
LFTs: AST 295 (H), ALT 496 (H), ALP 107, T.Bili 6.0 (H), Albumin 4.9.
Your liver blood test results: Liver enzymes (AST 295, ALT 496) are severely elevated, indicating significant liver damage (normal is under 40). Bilirubin is high at 6.0 (normal under 1.2) — may cause yellowing of skin and eyes [jaundice]. Albumin is normal at 4.9.
Gastroenterology
Lab Result
high
1,255
73 y/o F with PMH of Parkinson's disease, HTN, OA, HFpEF, admitted for chest pain r/o ACS. Serial troponins and cardiac monitoring performed. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on potassium chloride 20mEq daily, clopidogrel 75mg daily, gabapentin 300mg TID. F/U nephro...
A 73-year-old woman with a history of Parkinson's disease, high blood pressure, arthritis [osteoarthritis], and heart failure with stiff heart muscle was admitted for chest pain being evaluated for a possible heart attack. Serial troponins and cardiac monitoring performed. They were treated according to standard guidel...
Cardiology
Discharge Summary
high
1,256
45 y/o F with PMH of CAD, hypothyroidism, BPH, admitted for lower GI bleeding. Bright red blood per rectum. Hemoglobin dropping. Managed per protocol with improvement. Elevate R leg above heart level when resting. D/C on methotrexate 15mg weekly, entresto 49/51mg BID, atorvastatin 40mg QHS. F/U cardiology in 2 weeks.
A 45-year-old woman with a history of coronary artery disease [heart artery blockages], underactive thyroid, and enlarged prostate was admitted for bleeding from the large intestine. Bright red blood per rectum. Hemoglobin dropping. They were treated according to standard guidelines and improved. When resting, prop you...
Gastroenterology
Discharge Summary
high
1,257
80 y/o M presenting to ED with seizure witnessed by family, GTC x 3 min, postictal x 15 min. Vitals: BP 152/88, HR 98, T 98.6F, GCS 14 (postictal). CT Head: no hemorrhage. BMP: Na 128 (L). Keppra level <5 (subtherapeutic). Known seizure disorder, off meds x 1 week. Dx: Breakthrough seizure secondary to medication nonco...
A 80-year-old man came to the emergency room with a full-body seizure witnessed by family lasting about 3 minutes, followed by 15 minutes of confusion. Vital signs: blood pressure elevated (from seizure), heart rate slightly fast, no fever, mostly alert but still slightly confused. CT scan shows no bleeding. Sodium is ...
Emergency Medicine
Clinical Note
high
1,258
84 y/o M with PMH of CKD Stage 4, hypothyroidism, PAD, OSA on CPAP, anemia, admitted for lower GI bleeding. Bright red blood per rectum. Hemoglobin dropping. Managed per protocol with improvement. Wound care: daily dressing changes with wet-to-dry gauze. D/C on pregabalin 75mg BID, calcium + vitamin D 600/400 daily, gl...
A 84-year-old man with a history of advanced kidney disease, underactive thyroid, poor blood flow in the legs [peripheral artery disease], sleep apnea [uses a breathing machine at night], and low blood count [anemia] was admitted for bleeding from the large intestine. Bright red blood per rectum. Hemoglobin dropping. T...
Gastroenterology
Discharge Summary
high
1,259
Procedure: Laparoscopic appendectomy. Pt 35 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 keyhole surgery to remove the appendix for a 35-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.
General Surgery
Procedure Note
high
1,260
82 y/o M with PMH of HFpEF, PPM in situ, gout, hypothyroidism, admitted for fall with hip fracture. X-ray confirmed femoral neck fracture. Orthopedics consulted. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on ferrous sulfate 325mg BID, carvedilol 12.5mg BID, clopidogrel 75mg daily. F/U o...
A 82-year-old man with a history of heart failure with stiff heart muscle, implanted pacemaker, gout, and underactive thyroid 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. Be careful to prevent fal...
Orthopedics
Discharge Summary
high
1,261
Rx: Tab Dulcolax 10mg QHS PRN. Tab furosemide 40mg daily. Tab calcium + vitamin D 600/400 daily. Avoid grapefruit juice. F/U 6 weeks with LFTs.
Your medicines: (1) Dulcolax 10mg at bedtime as needed [for constipation]. (2) furosemide (Lasix) 40mg once daily [water pill to remove extra fluid]. (3) calcium plus vitamin D once daily [bone strengthening]. Do not drink grapefruit juice as it interferes with this medication. Come back in 6 weeks for liver function b...
General
Prescription
medium
1,262
Warfarin 5mg PO daily. INR goal 2.0-3.0. Avoid major diet changes in vitamin K. Report bleeding.
Take warfarin daily. Blood tests keep clotting in a safe range. Keep vitamin K intake steady and call your doctor for unusual bleeding.
Hematology
Medication Instruction
high
1,263
CT Head without contrast: No midline shift. Mild generalized cerebral atrophy appropriate for age. Paranasal sinuses clear. Acute ischemic infarct in R MCA territory. Chronic lacunar infarcts in bilateral basal ganglia.
CT scan of the head results: The brain is centered normally. There is mild brain shrinkage, which is normal for your age. The sinuses are clear with no infection. There is a new stroke affecting the right side of the brain, in the area supplied by the middle cerebral artery. There are signs of small old strokes in the ...
Neurology
Radiology Report
high
1,264
32 y/o F with PMH of OA, CAD, admitted for upper GI bleeding. Hematemesis noted. EGD showed bleeding ulcer. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on amoxicillin 500mg TID x 10 days, empagliflozin 10mg daily. F/U INR check in 3 days.
A 32-year-old woman with a history of arthritis [osteoarthritis], and coronary artery disease [heart artery blockages] was admitted for bleeding from the stomach or food pipe. Hematemesis noted. EGD showed bleeding ulcer. They were treated according to standard guidelines and improved. Be careful to prevent falls. Phys...
Gastroenterology
Discharge Summary
high
1,265
Rx: Humalog per SSI. Tab ondansetron 4mg Q8H PRN N/V. Adv: SMBG BID, diabetic diet. F/U 4 weeks with TSH, Free T4.
Your medicines: (1) Humalog insulin before meals as directed [fast-acting insulin]. (2) ondansetron (Zofran) 4mg every 8 hours as needed [anti-nausea medicine]. Advice: check your blood sugar twice daily and follow a diabetes-friendly diet. Come back in 4 weeks for thyroid blood tests [TSH and Free T4] to check if the ...
Endocrinology
Prescription
medium
1,266
CBC: WBC 13.6 (H), Hgb 17.1 (H), Plt 112 (L).
Your blood count results: White blood cells are 13.6 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is elevated at 17.1. Platelets are 112, which is low — your blood may not clot properly, increasing bleeding risk.
Hematology
Lab Result
high
1,267
US Abdomen: Spleen 16cm, splenomegaly. Moderate right hydronephrosis. Spleen 11cm, normal.
Abdominal ultrasound results: The spleen is enlarged [splenomegaly]. The right kidney is swollen because urine is backing up [hydronephrosis], possibly from a blockage. The spleen is a normal size.
Gastroenterology
Radiology Report
high
1,268
MRI Lumbar Spine: Conus medullaris at L1, normal. Central canal stenosis at L3-L4. No compression fracture.
MRI of the lower back results: The spinal cord ends at a normal level. The spinal canal is narrowed at L3-L4, which may be pressing on the nerves. No bones are broken or collapsed.
Orthopedics
Radiology Report
high
1,269
CXR PA: Elevated left hemidiaphragm. Right middle lobe atelectasis. Bilateral hilar lymphadenopathy.
Chest X-ray results: The left side of the breathing muscle [diaphragm] is sitting higher than normal. Part of the right lung has partially collapsed [atelectasis], possibly from mucus plugging. There are enlarged lymph nodes at the root of both lungs, which needs further evaluation.
Pulmonology
Radiology Report
high
1,270
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
1,271
CXR PA: No pneumothorax. Port-a-cath in appropriate position. Sternotomy wires intact.
Chest X-ray results: There is no collapsed lung. The implanted medication port is in the correct position. The wires from prior heart surgery are intact.
Pulmonology
Radiology Report
high
1,272
68 y/o F presenting to ED with acute onset SOB, unable to speak in full sentences. Vitals: BP 168/92, HR 118, RR 28, O2 85% on RA. CXR: bilateral pleural effusions, pulmonary edema. BNP 2400. Dx: Acute decompensated CHF. IV furosemide 80mg, BiPAP, nitroglycerin drip. Admit CCU.
A 68-year-old woman came to the emergency room with sudden severe difficulty breathing, unable to finish sentences. Vital signs: blood pressure high, heart rate very fast, breathing very rapid, oxygen dangerously low at 85%. Chest X-ray showed fluid in both lungs. Heart failure blood test very high. Diagnosis: severe h...
Emergency Medicine
Clinical Note
high
1,273
33 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 33-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
1,274
42 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 42-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
1,275
51 y/o M presenting to ED with seizure witnessed by family, GTC x 3 min, postictal x 15 min. Vitals: BP 152/88, HR 98, T 98.6F, GCS 14 (postictal). CT Head: no hemorrhage. BMP: Na 128 (L). Keppra level <5 (subtherapeutic). Known seizure disorder, off meds x 1 week. Dx: Breakthrough seizure secondary to medication nonco...
A 51-year-old man came to the emergency room with a full-body seizure witnessed by family lasting about 3 minutes, followed by 15 minutes of confusion. Vital signs: blood pressure elevated (from seizure), heart rate slightly fast, no fever, mostly alert but still slightly confused. CT scan shows no bleeding. Sodium is ...
Emergency Medicine
Clinical Note
high
1,276
Warfarin 5mg PO daily. INR goal 2.0-3.0. Avoid major diet changes in vitamin K. Report bleeding.
Take warfarin daily. Blood tests keep clotting in a safe range. Keep vitamin K intake steady and call your doctor for unusual bleeding.
Hematology
Medication Instruction
low
1,277
BMP: Na 128 (L), K 4.9 (N), BUN 37, Cr 3.2 (H), Glucose 113.
Your blood chemistry results: Sodium is low at 128 (normal 136-145), meaning too much water in your body. Potassium is normal at 4.9. Creatinine is elevated at 3.2 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 113 (high).
Nephrology
Lab Result
high
1,278
MRI Lumbar Spine: No compression fracture. Facet joint hypertrophy at L4-L5. Multilevel degenerative disc disease.
MRI of the lower back results: No bones are broken or collapsed. The small joints in the spine at L4-L5 are enlarged from arthritis. Multiple discs in the spine are showing wear and aging.
Orthopedics
Radiology Report
high
1,279
Rx: Tab montelukast 10mg QHS. Tab carvedilol 12.5mg BID. Tab lisinopril 20mg daily. Adv: high fiber diet, adequate hydration. F/U 2 weeks with INR.
Your medicines: (1) montelukast 10mg at bedtime [asthma/allergy medicine]. (2) carvedilol 12.5mg twice daily [heart medicine]. (3) lisinopril 20mg once daily [blood pressure medicine]. Advice: eat plenty of fiber (fruits, vegetables, whole grains) and drink enough water. Come back in 2 weeks for a blood thinner level c...
Cardiology
Prescription
medium
1,280
Rx: Tab furosemide 40mg BID. Tab Dulcolax 10mg QHS PRN. Tab potassium chloride 20mEq daily. Tab methotrexate 15mg weekly. Tab metformin 1000mg BID. Adv: DASH diet, daily BP monitoring Adv: elevate affected limb, compression stockings. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT.
Your medicines: (1) furosemide (Lasix) 40mg twice daily [water pill]. (2) Dulcolax 10mg at bedtime as needed [for constipation]. (3) potassium supplement 20mEq once daily [replaces potassium lost from water pills]. (4) methotrexate 15mg once weekly [immune-suppressing medicine for arthritis — requires monitoring]. (5) ...
General
Prescription
high
1,281
Rx: Tab metoprolol succinate 50mg daily. albuterol MDI 2 puffs Q4-6H PRN. Tab ondansetron 4mg Q8H PRN N/V. Tab furosemide 40mg BID. Lantus 20U QHS. Adv: fall precautions, home safety evaluation Avoid NSAIDs. F/U 1 month with repeat imaging.
Your medicines: (1) metoprolol 50mg once daily [heart rate and blood pressure medicine]. (2) albuterol inhaler 2 puffs every 4-6 hours as needed [rescue inhaler for breathing]. (3) ondansetron (Zofran) 4mg every 8 hours as needed [anti-nausea medicine]. (4) furosemide (Lasix) 40mg twice daily [water pill]. (5) Lantus i...
Cardiology
Prescription
high
1,282
BMP: Na 127 (L), K 5.4 (H), BUN 10, Cr 0.8 (N), Glucose 353.
Your blood chemistry results: Sodium is low at 127 (normal 136-145), meaning too much water in your body. Potassium is high at 5.4 — needs monitoring. Creatinine is normal at 0.8. Blood sugar is 353 (high).
Nephrology
Lab Result
high
1,283
HbA1c: 7.0% (H). FBS: 390 mg/dL (H).
Your diabetes blood test results: HbA1c is 7.0%, which is above the target of 7.0%. Your blood sugar has been somewhat poorly controlled over the past 3 months. Fasting blood sugar was 390, which is high (normal is 70-100). Your diabetes medicines may need adjustment. Discuss with your doctor.
Endocrinology
Lab Result
high
1,284
89 y/o F presenting to ED with severe allergic reaction after eating shellfish, diffuse urticaria, lip/tongue swelling, wheezing. Vitals: BP 82/50, HR 132, RR 28, O2 90%. Clinical diagnosis of anaphylaxis based on exam. Dx: Anaphylaxis. Epinephrine 0.3mg IM x 2 doses. IV NS 2L bolus. IV methylprednisolone 125mg. IV dip...
A 89-year-old woman came to the emergency room with severe allergic reaction after eating shellfish — hives all over body, lips and tongue swelling, wheezing. Vital signs: blood pressure dangerously low (shock), heart rate very fast, breathing rapid, oxygen low. Examination and vital signs support a severe systemic all...
Emergency Medicine
Clinical Note
high
1,285
28 y/o F with PMH of Parkinson's disease, A-fib, s/p THR, HFrEF (EF 30%), admitted for sepsis secondary to cellulitis. Blood cultures drawn. IV antibiotics started emergently. Managed per protocol with improvement. Elevate R leg above heart level when resting. D/C on acetaminophen 650mg Q6H PRN, levothyroxine 75mcg dai...
A 28-year-old woman with a history of Parkinson's disease, irregular heartbeat [atrial fibrillation], prior hip replacement, and heart failure with weak pumping (30%) was admitted for a serious blood infection from a skin infection. Blood cultures drawn. IV antibiotics started emergently. They were treated according to...
Infectious Disease
Discharge Summary
high
1,286
BMP: Na 148 (H), K 6.4 (H), BUN 83, Cr 7.2 (H), Glucose 164.
Your blood chemistry results: Sodium is high at 148, meaning you may be dehydrated. Potassium is dangerously high at 6.4 (normal 3.5-5.0) — this can affect your heart and needs immediate treatment. Creatinine is elevated at 7.2 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 164 (high...
Nephrology
Lab Result
high
1,287
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
1,288
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
high
1,289
Rx: Tab metformin 1000mg BID. Tab gabapentin 300mg TID. Adv: avoid alcohol, hepatotoxic drugs. F/U PCP in 1 week for BP recheck.
Your medicines: (1) metformin 1000mg twice daily with meals [blood sugar medicine]. (2) gabapentin 300mg three times daily [nerve pain medicine — may cause drowsiness]. Advice: do not drink alcohol and avoid medications that can harm the liver (including acetaminophen in excess). See your primary care doctor in 1 week ...
Pediatrics
Prescription
medium
1,290
75 y/o M with PMH of s/p THR, ICD in situ, A-fib, admitted for fall with hip fracture. X-ray confirmed femoral neck fracture. Orthopedics consulted. Managed per protocol with improvement. Head injury precautions x 48hrs. D/C on prednisone taper, methotrexate 15mg weekly. F/U surgery in 10 days.
A 75-year-old man with a history of prior hip replacement, implanted heart defibrillator, and irregular heartbeat [atrial fibrillation] 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. Watch for: wors...
Orthopedics
Discharge Summary
high
1,291
34 y/o F presenting to ED with seizure witnessed by family, GTC x 3 min, postictal x 15 min. Vitals: BP 152/88, HR 98, T 98.6F, GCS 14 (postictal). CT Head: no hemorrhage. BMP: Na 128 (L). Keppra level <5 (subtherapeutic). Known seizure disorder, off meds x 1 week. Dx: Breakthrough seizure secondary to medication nonco...
A 34-year-old woman came to the emergency room with a full-body seizure witnessed by family lasting about 3 minutes, followed by 15 minutes of confusion. Vital signs: blood pressure elevated (from seizure), heart rate slightly fast, no fever, mostly alert but still slightly confused. CT scan shows no bleeding. Sodium i...
Emergency Medicine
Clinical Note
high
1,292
Rivaroxaban 15mg BID x 21d then 20mg daily with food for PE.
Blood thinner dosing changes after the first 3 weeks — always take with food as instructed for lung clots.
Pulmonology
Medication Instruction
high
1,293
Rx: Tab calcium + vitamin D 600/400 daily. Tab Dulcolax 10mg QHS PRN. Adv: high fiber diet, adequate hydration. F/U 2 weeks.
Your medicines: (1) calcium plus vitamin D once daily [bone strengthening]. (2) Dulcolax 10mg at bedtime as needed [for constipation]. Advice: eat plenty of fiber (fruits, vegetables, whole grains) and drink enough water. Come back for a check-up in 2 weeks.
General
Prescription
medium
1,294
Lipid panel: TC 120, LDL 172, HDL 53, TG 342.
Your cholesterol results: Total cholesterol is 120. LDL (bad cholesterol) is very high at 172 (goal under 100), significantly increasing heart disease risk. HDL (good cholesterol) is good at 53. Triglycerides are very high at 342 (normal under 150) — increases risk of pancreatitis.
Cardiology
Lab Result
high
1,295
52 y/o M presenting to ED with altered mental status, found unresponsive at home. Vitals: BP 88/52, HR 128, RR 8, T 96.2F, O2 88%, GCS 8. Glucose 32 (L). UDS positive for opioids. Narcan 2mg IV x 2 with improvement. Dx: Mixed presentation: hypoglycemia + opioid overdose. D50 IV push, Narcan drip. Monitor for re-sedatio...
A 52-year-old man came to the emergency room with found unconscious at home, not responding normally. Vital signs: blood pressure dangerously low, heart rate very fast, breathing slow, temperature low, oxygen very low, barely responsive. Blood sugar was dangerously low at 32. Drug screen positive for opioids. Narcan (o...
Emergency Medicine
Clinical Note
high
1,296
Thyroid panel: TSH 4.43 (N), Free T4 0.8.
Your thyroid test results: TSH is normal at 4.43. Free T4 is normal — your thyroid function is balanced.
Endocrinology
Lab Result
medium
1,297
PATH: Breast: IDC, Nottingham grade 2, ER/PR positive, HER2 negative, margins negative.
Pathology results in plain language: Breast biopsy shows invasive ductal carcinoma, moderately aggressive. Hormone receptors positive (often treatable with hormone therapy). HER2 negative. Edges of tissue clear of cancer.
Oncology
Pathology Report
high
1,298
Rx: Tab montelukast 10mg QHS. Tab rosuvastatin 10mg QHS. Adv: low salt low sugar diet, regular exercise Adv: fall precautions, home safety evaluation. F/U 1 month with repeat imaging.
Your medicines: (1) montelukast 10mg at bedtime [asthma/allergy medicine]. (2) rosuvastatin 10mg at bedtime [cholesterol medicine]. Advice: eat less salt and sugar, and exercise at least 30 minutes most days Advice: take steps to prevent falls — remove loose rugs, install grab bars, use night lights. Come back in 1 mon...
Cardiology
Prescription
medium
1,299
HbA1c: 13.4% (H). FBS: 99 mg/dL (N).
Your diabetes blood test results: HbA1c is 13.4%, which is very high, meaning blood sugar has been dangerously uncontrolled (target is under 7%). Fasting blood sugar was 99, which is normal (normal is 70-100). Urgent medication adjustment needed. Very high risk of diabetes complications at this level.
Endocrinology
Lab Result
high
1,300
Procedure: EGD with biopsy. Pt 63 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 upper endoscopy with small tissue samples taken for a 63-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