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1,401 | 25 y/o M presenting to ED with worst headache of my life, acute onset 2hrs ago. Vitals: BP 172/94, HR 78, GCS 15. CT Head: negative. LP: xanthochromic CSF, RBC 11000. CTA: 5mm ACOM aneurysm. Dx: SAH secondary to ruptured aneurysm. Nimodipine started. Neurosurgery consulted. Transfer to neuro ICU. | A 25-year-old man came to the emergency room with the worst headache of his/her life, started suddenly 2 hours ago. Vital signs: blood pressure elevated, heart rate normal, fully alert. CT scan did not show bleeding. Spinal tap showed blood in spinal fluid confirming brain bleed. Blood vessel scan found a 5mm bulge [an... | Emergency Medicine | Clinical Note | high |
1,402 | 38 y/o M with PMH of A-fib, SLE, ICD in situ, admitted for TIA. Symptoms resolved. MRI negative for infarct. Managed per protocol with improvement. Smoking cessation counseling provided. D/C on metformin 1000mg BID, ciprofloxacin 500mg BID x 5 days, ASA 81mg daily, methotrexate 15mg weekly, Eliquis 5mg BID. F/U cardiol... | A 38-year-old man with a history of irregular heartbeat [atrial fibrillation], lupus, and implanted heart defibrillator was admitted for a mini-stroke [temporary loss of brain function]. Symptoms resolved. MRI negative for infarct. They were treated according to standard guidelines and improved. Strongly encouraged to ... | Neurology | Discharge Summary | high |
1,403 | Procedure: TURP for BPH. Pt 64 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 64-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 |
1,404 | 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 |
1,405 | Rx: Tab amoxicillin 500mg TID x 10 days. Tab entresto 49/51mg BID. Tab Xarelto 20mg daily with dinner. prednisone taper. Tab ASA 81mg daily. Adv: low potassium diet. F/U 1 week with CBC, CMP. | Your medicines: (1) amoxicillin 500mg three times daily for 10 days [antibiotic — complete full course]. (2) Entresto 49/51mg twice daily [heart failure medicine]. (3) Xarelto 20mg once daily with dinner [blood thinner]. (4) prednisone steroid — dose gradually decreases as directed [do not stop suddenly]. (5) baby aspi... | Cardiology | Prescription | high |
1,406 | 83 y/o F with PMH of HTN, CHF, COPD, admitted for atrial fibrillation with RVR. HR 150s. Diltiazem drip started for rate control. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on rosuvastatin 10mg QHS, amlodipine 5mg daily, methotrexate 15mg weekly, escitalopram 10mg daily, losa... | A 83-year-old woman with a history of high blood pressure, heart failure, and chronic lung disease was admitted for irregular heartbeat with dangerously fast rate. HR 150s. Diltiazem drip started for rate control. They were treated according to standard guidelines and improved. Write down your blood sugar readings in a... | Cardiology | Discharge Summary | high |
1,407 | 50 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 50-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 |
1,408 | MRI Lumbar Spine: No compression fracture. Multilevel degenerative disc disease. L4-L5 disc herniation with moderate bilateral foraminal stenosis. Conus medullaris at L1, normal. | MRI of the lower back results: No bones are broken or collapsed. Multiple discs in the spine are showing wear and aging. At the L4-L5 level, a disc has pushed outward [herniated] and is narrowing the nerve tunnels on both sides. The spinal cord ends at a normal level. | Orthopedics | Radiology Report | high |
1,409 | 41 y/o F with PMH of HFrEF (EF 30%), seizure disorder on Keppra, HLD, osteoporosis, OA, admitted for lower GI bleeding. Bright red blood per rectum. Hemoglobin dropping. Managed per protocol with improvement. Seizure precautions, do not drive x 6 months. D/C on lisinopril 20mg daily, tramadol 50mg Q6H PRN pain. F/U hem... | A 41-year-old woman with a history of heart failure with weak pumping (30%), seizure disorder [on Keppra], high cholesterol, weak bones [osteoporosis], and arthritis [osteoarthritis] was admitted for bleeding from the large intestine. Bright red blood per rectum. Hemoglobin dropping. They were treated according to stan... | Gastroenterology | Discharge Summary | high |
1,410 | 44 y/o M presenting to ED with worst headache of my life, acute onset 2hrs ago. Vitals: BP 172/94, HR 78, GCS 15. CT Head: negative. LP: xanthochromic CSF, RBC 11000. CTA: 5mm ACOM aneurysm. Dx: SAH secondary to ruptured aneurysm. Nimodipine started. Neurosurgery consulted. Transfer to neuro ICU. | A 44-year-old man came to the emergency room with the worst headache of his/her life, started suddenly 2 hours ago. Vital signs: blood pressure elevated, heart rate normal, fully alert. CT scan did not show bleeding. Spinal tap showed blood in spinal fluid confirming brain bleed. Blood vessel scan found a 5mm bulge [an... | Emergency Medicine | Clinical Note | high |
1,411 | CT Head without contrast: Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. Subarachnoid hemorrhage in bilateral sylvian fissures. No mass effect. | CT scan of the head results: There are aging-related changes in the brain's white matter from reduced blood flow to small vessels over time. There is bleeding around the brain surface, particularly in the grooves on both sides. There are no tumors or masses pushing on the brain. | Neurology | Radiology Report | high |
1,412 | 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 |
1,413 | Rx: Tab lisinopril 10mg daily. Tab ciprofloxacin 500mg BID x 5 days. Avoid grapefruit juice. F/U 2 weeks with INR. | Your medicines: (1) lisinopril 10mg once daily [blood pressure medicine that also protects kidneys]. (2) ciprofloxacin 500mg twice daily for 5 days [antibiotic — avoid dairy within 2 hours]. Do not drink grapefruit juice as it interferes with this medication. Come back in 2 weeks for a blood thinner level check [INR]. | Pediatrics | Prescription | medium |
1,414 | Rx: Tab atorvastatin 40mg QHS. Tab carvedilol 12.5mg BID. Avoid grapefruit juice Adv: avoid alcohol, hepatotoxic drugs. F/U 4 weeks with TSH, Free T4. | Your medicines: (1) atorvastatin 40mg at bedtime [cholesterol medicine]. (2) carvedilol 12.5mg twice daily [heart medicine]. Do not drink grapefruit juice as it interferes with this medication Advice: do not drink alcohol and avoid medications that can harm the liver (including acetaminophen in excess). Come back in 4 ... | Cardiology | Prescription | medium |
1,415 | MRI Lumbar Spine: L5-S1 disc desiccation with mild bulge. L4-L5 disc herniation with moderate bilateral foraminal stenosis. C5-C6 disc herniation with cord compression. | MRI of the lower back results: 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. At C5-C6 in the neck, a disc has pushed out and is pressing on the spinal... | Orthopedics | Radiology Report | high |
1,416 | 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 |
1,417 | Rx: Tab sertraline 50mg daily. Spiriva 18mcg daily. Adv: wound care with daily dressing changes. F/U 4 weeks with TSH, Free T4. | Your medicines: (1) sertraline 50mg once daily [antidepressant/anxiety medicine]. (2) Spiriva inhaler once daily [long-acting lung medicine]. Advice: change the wound dressing once daily — clean with saline, apply ointment, cover with fresh bandage. Come back in 4 weeks for thyroid blood tests [TSH and Free T4] to chec... | Pulmonology | Prescription | medium |
1,418 | HbA1c: 8.8% (H). FBS: 199 mg/dL (H). | Your diabetes blood test results: HbA1c is 8.8%, which is high, meaning your blood sugar has been poorly controlled over the past 3 months (target is under 7%). Fasting blood sugar was 199, which is high (normal is 70-100). Your diabetes treatment needs to be changed. This level increases risk of complications. | Endocrinology | Lab Result | high |
1,419 | MRI Lumbar Spine: Central canal stenosis at L3-L4. L5-S1 disc desiccation with mild bulge. | MRI of the lower back results: The spinal canal is narrowed at L3-L4, which may be pressing on the nerves. At the L5-S1 level, the disc is dried out [worn] with a slight bulge, but not causing significant pressure. | Orthopedics | Radiology Report | high |
1,420 | Delivery Note: G?P? at 38+2 weeks. SVD. Live male infant. APGAR 7/9. EBL within expected limits. Mother stable. | Birth summary: pregnancy reached about 38+2 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 |
1,421 | MRI Lumbar Spine: Conus medullaris at L1, normal. Central canal stenosis at L3-L4. | 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. | Orthopedics | Radiology Report | high |
1,422 | 54 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 54-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 |
1,423 | Delivery Note: G?P? at 39+1 weeks. SVD. Live female infant. APGAR 7/9. EBL within expected limits. Mother stable. | Birth summary: pregnancy reached about 39+1 weeks gestation. The baby was delivered by normal vaginal delivery. The newborn is a healthy female. APGAR scores were 7/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
1,424 | MRI Lumbar Spine: Facet joint hypertrophy at L4-L5. Central canal stenosis at L3-L4. | MRI of the lower back results: The small joints in the spine at L4-L5 are enlarged from arthritis. The spinal canal is narrowed at L3-L4, which may be pressing on the nerves. | Orthopedics | Radiology Report | high |
1,425 | Rx: Tab clopidogrel 75mg daily. Tab furosemide 40mg daily. Tab lisinopril 20mg daily. Tab furosemide 40mg BID. Tab sertraline 50mg daily. Adv: low potassium diet. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT. | Your medicines: (1) Plavix (clopidogrel) 75mg once daily [blood thinner]. (2) furosemide (Lasix) 40mg once daily [water pill to remove extra fluid]. (3) lisinopril 20mg once daily [blood pressure medicine]. (4) furosemide (Lasix) 40mg twice daily [water pill]. (5) sertraline 50mg once daily [antidepressant/anxiety medi... | Cardiology | Prescription | high |
1,426 | 86 y/o M with PMH of seizure disorder on Keppra, gout, admitted for AECOPD. O2 sat dropped. Required supplemental oxygen. Managed per protocol with improvement. Wound care: daily dressing changes with wet-to-dry gauze. D/C on atorvastatin 40mg QHS, Spiriva 18mcg daily, Humalog per SSI. F/U INR check in 3 days. | A 86-year-old man with a history of seizure disorder [on Keppra], and gout was admitted for a severe flare-up of chronic lung disease. Oxygen levels dropped. Required supplemental oxygen. They were treated according to standard guidelines and improved. Change the wound dressing daily: wet the gauze with saline, place o... | Pulmonology | Discharge Summary | high |
1,427 | Procedure: ORIF L distal radius. Pt 29 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 29-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 |
1,428 | 83 y/o F with PMH of ICD in situ, OSA on CPAP, admitted for DKA. Blood sugar >500. pH 7.1. Anion gap elevated. Managed per protocol with improvement. Strict I&O, daily weights. D/C on tramadol 50mg Q6H PRN pain, potassium chloride 20mEq daily, omeprazole 20mg AC breakfast, carvedilol 12.5mg BID, prednisone taper. F/U s... | A 83-year-old woman with a history of implanted heart defibrillator, and sleep apnea [uses a breathing machine at night] 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... | Endocrinology | Discharge Summary | high |
1,429 | Rx: Tab metoprolol succinate 50mg daily. Tab sertraline 50mg daily. Lantus 20U QHS. Adv: fall precautions, home safety evaluation Adv: elevate affected limb, compression stockings. F/U 1 week with wound check. | Your medicines: (1) metoprolol 50mg once daily [heart rate and blood pressure medicine]. (2) sertraline 50mg once daily [antidepressant/anxiety medicine]. (3) Lantus insulin 20 units at bedtime [long-acting insulin]. Advice: take steps to prevent falls — remove loose rugs, install grab bars, use night lights Advice: ke... | Cardiology | Prescription | medium |
1,430 | 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 | low |
1,431 | CT Head without contrast: Mild generalized cerebral atrophy appropriate for age. Chronic lacunar infarcts in bilateral basal ganglia. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. No acute intracranial hemorrhage. | CT scan of the head results: There is mild brain shrinkage, which is normal for your age. 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 no bleeding in the brain. | Neurology | Radiology Report | high |
1,432 | 78 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 78-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 |
1,433 | 51 y/o F presenting to ED with RLQ pain x 12hrs, anorexia, low-grade fever. Vitals: BP 128/76, HR 96, T 100.8F. CT abdomen: 9mm dilated appendix with periappendiceal fat stranding, no perforation. Dx: Acute uncomplicated appendicitis. NPO, IV Zosyn. Surgery consulted for laparoscopic appendectomy. Admit surgery. | A 51-year-old woman came to the emergency room with pain in the lower right belly for 12 hours, loss of appetite, and mild fever. Vital signs: blood pressure normal, heart rate slightly fast, mild fever. CT scan showed the appendix is swollen (9mm, normal <6mm) with inflammation around it but no rupture. Diagnosis: app... | Emergency Medicine | Clinical Note | high |
1,434 | US Abdomen: Spleen 11cm, normal. CBD 5mm, not dilated. Liver 18cm, diffusely echogenic consistent with hepatic steatosis. GB sludge, no stones. Ascites moderate amount. Spleen 16cm, splenomegaly. | Abdominal ultrasound results: The spleen is a normal size. The bile duct is normal size [not blocked]. The liver is slightly enlarged and appears brighter than normal, indicating fatty liver disease. The gallbladder contains thickened bile [sludge] but no stones. There is a moderate amount of fluid in the belly [ascite... | Gastroenterology | Radiology Report | high |
1,435 | US Abdomen: Pancreas unremarkable. Left kidney 8cm, cortical thinning consistent with CKD. Simple renal cysts bilaterally. | Abdominal ultrasound results: The pancreas looks normal. Left kidney is small with thin outer layer, consistent with chronic kidney disease. Both kidneys have harmless fluid-filled cysts. | Gastroenterology | Radiology Report | high |
1,436 | US Abdomen: GB wall thickening with stones, positive Murphy's sign. Right kidney 10.5cm, no hydronephrosis. No focal hepatic lesion. GB sludge, no stones. | Abdominal ultrasound results: The gallbladder wall is thickened and gallstones are present — pressing on the gallbladder area caused pain [positive Murphy's sign], suggesting infection. Right kidney is normal size with no blockage. No tumors or masses were found in the liver. The gallbladder contains thickened bile [sl... | Gastroenterology | Radiology Report | high |
1,437 | 53 y/o M with PMH of CKD Stage 3, PAD, HFpEF, s/p TKR, PPM in situ, admitted for upper GI bleeding. Hematemesis noted. EGD showed bleeding ulcer. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on ciprofloxacin 500mg BID x 5 days, latanoprost 0.005% OU QHS, calcium + vitamin D 600... | A 53-year-old man with a history of moderate kidney disease, poor blood flow in the legs [peripheral artery disease], heart failure with stiff heart muscle, prior knee replacement, and implanted pacemaker was admitted for bleeding from the stomach or food pipe. Hematemesis noted. EGD showed bleeding ulcer. They were tr... | Gastroenterology | Discharge Summary | high |
1,438 | 46 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 46-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 |
1,439 | 41 y/o F with PMH of anemia, gout, admitted for hypertensive urgency. BP 210/120. IV medications started to lower gradually. Managed per protocol with improvement. Strict NPO after midnight before procedure. D/C on ondansetron 4mg Q8H PRN N/V, carvedilol 12.5mg BID. F/U surgery in 2 weeks for drain removal. | A 41-year-old woman with a history of low blood count [anemia], and gout was admitted for dangerously high blood pressure. BP 210/120. IV medications started to lower gradually. They were treated according to standard guidelines and improved. Do not eat or drink anything after midnight the night before your procedure..... | Cardiology | Discharge Summary | high |
1,440 | Procedure: ORIF L distal radius. Pt 82 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 surgery to fix a wrist fracture with plate and screws for a 82-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. | Orthopedics | Procedure Note | high |
1,441 | 60 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 60-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 |
1,442 | Delivery Note: G?P? at 37+3 weeks. Primary low-transverse C-section. Live female infant. APGAR 7/9. 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 7/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
1,443 | 68 y/o M with PMH of DVT/PE on warfarin, cirrhosis, 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 latanoprost 0.005% OU QHS, losartan 50mg daily, ondansetron 4mg Q8H PRN N/V, omepr... | A 68-year-old man with a history of blood clots [on blood thinner warfarin], and liver scarring [cirrhosis] was admitted for bleeding from the large intestine. Bright red blood per rectum. Hemoglobin dropping. They were treated according to standard guidelines and improved. Change the wound dressing daily: wet the gauz... | Gastroenterology | Discharge Summary | high |
1,444 | 29 y/o M with PMH of s/p CABG, PPM in situ, anemia, admitted for cellulitis L lower extremity. Area was red, warm, and swollen. Marked with pen to track spread. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on Spiriva 18mcg daily, levothyroxine 75mcg daily on empty stoma... | A 29-year-old man with a history of prior heart bypass surgery, implanted pacemaker, and low blood count [anemia] was admitted for a skin infection in the left leg. Area was red, warm, and swollen. Marked with pen to track spread. They were treated according to standard guidelines and improved. Use the breathing exerci... | Infectious Disease | Discharge Summary | high |
1,445 | 84 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 84-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 |
1,446 | Rx: Tab hydroxychloroquine 200mg BID. Tab clopidogrel 75mg daily. Lantus 20U QHS. Adv: low potassium diet. F/U 1 week with wound check. | Your medicines: (1) hydroxychloroquine 200mg twice daily [immune-modulating medicine — eye exams needed]. (2) Plavix (clopidogrel) 75mg once daily [blood thinner]. (3) Lantus insulin 20 units at bedtime [long-acting insulin]. Advice: avoid high-potassium foods like bananas, oranges, potatoes, and tomatoes. Come back in... | Cardiology | Prescription | medium |
1,447 | Rx: Tab acetaminophen 650mg Q6H PRN. albuterol MDI 2 puffs Q4-6H PRN. Tab Xarelto 20mg daily with dinner. Tab ciprofloxacin 500mg BID x 5 days. Adv: smoking cessation, pulmonary rehab. F/U 2 weeks. | Your medicines: (1) Tylenol (acetaminophen) 650mg every 6 hours as needed [do not exceed 3000mg/day]. (2) albuterol inhaler 2 puffs every 4-6 hours as needed [rescue inhaler for breathing]. (3) Xarelto 20mg once daily with dinner [blood thinner]. (4) ciprofloxacin 500mg twice daily for 5 days [antibiotic — avoid dairy ... | Pulmonology | Prescription | high |
1,448 | 38 y/o M 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 38-year-old man 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 aller... | Emergency Medicine | Clinical Note | high |
1,449 | Rx: albuterol MDI 2 puffs Q4-6H PRN. Tab ASA 81mg daily. Tab levothyroxine 75mcg daily on empty stomach. Spiriva 18mcg daily. Adv: low potassium diet. F/U 1 week with wound check. | Your medicines: (1) albuterol inhaler 2 puffs every 4-6 hours as needed [rescue inhaler for breathing]. (2) baby aspirin 81mg once daily [prevents blood clots]. (3) levothyroxine 75mcg on empty stomach 30 min before breakfast [thyroid medicine]. (4) Spiriva inhaler once daily [long-acting lung medicine]. Advice: avoid ... | Pulmonology | Prescription | high |
1,450 | 52 y/o F with PMH of ESRD on HD, osteoporosis, cirrhosis, admitted for alcohol withdrawal. CIWA protocol initiated. Lorazepam given as needed. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on hydroxychloroquine 200mg BID, lisinopril 10mg daily, furosemide 40mg BID, amlodipine 5mg daily, la... | A 52-year-old woman with a history of kidney failure requiring dialysis, weak bones [osteoporosis], and liver scarring [cirrhosis] was admitted for withdrawal symptoms after stopping alcohol. CIWA protocol initiated. Lorazepam given as needed. They were treated according to standard guidelines and improved. Be careful ... | Psychiatry | Discharge Summary | high |
1,451 | 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 |
1,452 | Procedure: Laparoscopic appendectomy. Pt 64 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 64-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 |
1,453 | BMP: Na 123 (L), K 4.0 (N), BUN 49, Cr 5.1 (H), Glucose 283. | Your blood chemistry results: Sodium is low at 123 (normal 136-145), meaning too much water in your body. Potassium is normal at 4.0. Creatinine is elevated at 5.1 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 283 (high). | Nephrology | Lab Result | high |
1,454 | LFTs: AST 335 (H), ALT 316 (H), ALP 239, T.Bili 6.7 (H), Albumin 1.6. | Your liver blood test results: Liver enzymes (AST 335, ALT 316) are severely elevated, indicating significant liver damage (normal is under 40). Bilirubin is high at 6.7 (normal under 1.2) — may cause yellowing of skin and eyes [jaundice]. Albumin is low at 1.6 (normal 3.5-5.5), suggesting the liver is struggling to ma... | Gastroenterology | Lab Result | high |
1,455 | 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 |
1,456 | CXR PA: Mild cardiomegaly. Sternotomy wires intact. Moderate right pleural effusion. Cardiomegaly with CTR >0.5. Right middle lobe atelectasis. | Chest X-ray results: The heart is slightly larger than normal. The wires from prior heart surgery are intact. There is a moderate amount of fluid around the right lung. The heart appears larger than normal. Part of the right lung has partially collapsed [atelectasis], possibly from mucus plugging. | Pulmonology | Radiology Report | high |
1,457 | Rx: Tab methotrexate 15mg weekly. Tab acetaminophen 650mg Q6H PRN. Tab Eliquis 5mg BID. Tab calcium + vitamin D 600/400 daily. Tab omeprazole 20mg AC breakfast. Adv: weight bearing exercise, calcium/vit D supplementation. F/U 1 month with repeat imaging. | Your medicines: (1) methotrexate 15mg once weekly [immune-suppressing medicine for arthritis — requires monitoring]. (2) Tylenol (acetaminophen) 650mg every 6 hours as needed [do not exceed 3000mg/day]. (3) Eliquis 5mg twice daily [blood thinner]. (4) calcium plus vitamin D once daily [bone strengthening]. (5) omeprazo... | General | Prescription | high |
1,458 | 87 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 87-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 |
1,459 | CXR PA: ET tube 3cm above carina. Osseous structures intact. Moderate right pleural effusion. Mild cardiomegaly. Bilateral pleural effusions. | Chest X-ray results: The breathing tube is in good position. The bones look normal with no fractures. There is a moderate amount of fluid around the right lung. The heart is slightly larger than normal. There is fluid collecting around both lungs. | Pulmonology | Radiology Report | high |
1,460 | CBC: WBC 3.1 (L), Hgb 15.7 (N), Plt 169 (N). | Your blood count results: White blood cells are 3.1 (low, meaning your immune system may be weakened). Hemoglobin is normal at 15.7. Platelets are 169, which is normal. | Hematology | Lab Result | high |
1,461 | 71 y/o F 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 71-year-old woman 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 ... | Emergency Medicine | Clinical Note | high |
1,462 | CBC: WBC 16.1 (H), Hgb 13.7 (N), Plt 476 (H). | Your blood count results: White blood cells are 16.1 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is normal at 13.7. Platelets are 476, which is high — your blood may clot too easily. | Hematology | Lab Result | high |
1,463 | 65 y/o M with PMH of anemia, HTN, CHF, admitted for atrial fibrillation with RVR. HR 150s. Diltiazem drip started for rate control. Managed per protocol with improvement. Strict I&O, daily weights. D/C on levothyroxine 75mcg daily on empty stomach, Augmentin 875/125 BID x 7 days, omeprazole 20mg AC breakfast. F/U PCP i... | A 65-year-old man with a history of low blood count [anemia], high blood pressure, and heart failure was admitted for irregular heartbeat with dangerously fast rate. HR 150s. Diltiazem drip started for rate control. They were treated according to standard guidelines and improved. Track how much you drink and urinate. W... | Cardiology | Discharge Summary | high |
1,464 | Procedure: Colonoscopy with polypectomy. Pt 34 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 34-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 |
1,465 | 80 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 80-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 |
1,466 | Rx: Tab amlodipine 5mg daily. albuterol MDI 2 puffs Q4-6H PRN. Tab latanoprost 0.005% OU QHS. Adv: weight bearing exercise, calcium/vit D supplementation. F/U PCP in 1 week for BP recheck. | Your medicines: (1) amlodipine 5mg once daily [blood pressure medicine]. (2) albuterol inhaler 2 puffs every 4-6 hours as needed [rescue inhaler for breathing]. (3) latanoprost eye drops in both eyes at bedtime [glaucoma medicine]. Advice: do weight-bearing exercises (walking, light weights) and take calcium and vitami... | Cardiology | Prescription | medium |
1,467 | CT Head without contrast: Subarachnoid hemorrhage in bilateral sylvian fissures. No acute intracranial hemorrhage. Acute ischemic infarct in R MCA territory. | CT scan of the head results: There is bleeding around the brain surface, particularly in the grooves on both sides. There is no bleeding in the brain. 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 |
1,468 | Rx: Tab spironolactone 25mg daily. Tab atorvastatin 80mg QHS. Tab glipizide 5mg BID AC. Tab azithromycin 500mg day 1 then 250mg x 4 days. Tab amlodipine 5mg daily. Adv: low salt diet, fluid restriction 1.5L/day. F/U 6 weeks with LFTs. | Your medicines: (1) spironolactone 25mg once daily [heart-protecting water pill]. (2) atorvastatin 80mg at bedtime [high-dose cholesterol medicine]. (3) glipizide 5mg twice daily before meals [helps release insulin]. (4) azithromycin: 500mg on day 1, then 250mg for the next 4 days [antibiotic]. (5) amlodipine 5mg once ... | Cardiology | Prescription | high |
1,469 | 64 y/o F 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 64-year-old woman 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 ... | Emergency Medicine | Clinical Note | high |
1,470 | 29 y/o M with PMH of s/p CABG, DM1, OSA on CPAP, admitted for HHS. Blood sugar >800. Severe dehydration. Managed per protocol with improvement. Diabetic diet, SMBG BID. D/C on lisinopril 10mg daily, clopidogrel 75mg daily, hydroxychloroquine 200mg BID. F/U INR check in 3 days. | A 29-year-old man with a history of prior heart bypass surgery, type 1 diabetes, and sleep apnea [uses a breathing machine at night] was admitted for hyperosmolar hyperglycemic state [extremely high blood sugar]. Blood sugar >800. Severe dehydration. They were treated according to standard guidelines and improved. Foll... | Endocrinology | Discharge Summary | high |
1,471 | 28 y/o F with PMH of RA on MTX, h/o TIA, admitted for acute CHF exacerbation. BNP elevated. CXR showed pulmonary edema. Managed per protocol with improvement. Wound care: daily dressing changes with wet-to-dry gauze. D/C on escitalopram 10mg daily, losartan 50mg daily, hydroxychloroquine 200mg BID. F/U pulmonology in 2... | A 28-year-old woman with a history of rheumatoid arthritis [on immune-suppressing medicine], and history of mini-stroke 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. Change the wound dressin... | Cardiology | Discharge Summary | high |
1,472 | Rx: Tab ondansetron 4mg Q8H PRN N/V. Humalog per SSI. Tab metformin 500mg BID. Tab clopidogrel 75mg daily. Adv: weight bearing exercise, calcium/vit D supplementation Adv: fall precautions, home safety evaluation. F/U 1 month with repeat imaging. | Your medicines: (1) ondansetron (Zofran) 4mg every 8 hours as needed [anti-nausea medicine]. (2) Humalog insulin before meals as directed [fast-acting insulin]. (3) metformin 500mg twice daily with meals [blood sugar medicine]. (4) Plavix (clopidogrel) 75mg once daily [blood thinner]. Advice: do weight-bearing exercise... | Endocrinology | Prescription | high |
1,473 | CBC: WBC 5.8 (N), Hgb 7.1 (L), Plt 428 (H). | Your blood count results: White blood cells are 5.8 (normal). Hemoglobin is low at 7.1, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 428, which is high — your blood may clot too easily. | Hematology | Lab Result | high |
1,474 | Rx: Tab ciprofloxacin 500mg BID x 5 days. Tab atorvastatin 40mg QHS. Tab Augmentin 875/125 BID x 7 days. Tab atorvastatin 80mg QHS. Tab montelukast 10mg QHS. Adv: low potassium diet Adv: wound care with daily dressing changes. F/U 1 week with wound check. | Your medicines: (1) ciprofloxacin 500mg twice daily for 5 days [antibiotic — avoid dairy within 2 hours]. (2) atorvastatin 40mg at bedtime [cholesterol medicine]. (3) Augmentin 875mg twice daily for 7 days [antibiotic]. (4) atorvastatin 80mg at bedtime [high-dose cholesterol medicine]. (5) montelukast 10mg at bedtime [... | Cardiology | Prescription | high |
1,475 | Rx: Tab warfarin 5mg daily. Tab pantoprazole 40mg AC breakfast. Tab tramadol 50mg Q6H PRN pain. Tab Xarelto 20mg daily with dinner. Adv: avoid alcohol, hepatotoxic drugs Adv: weight bearing exercise, calcium/vit D supplementation. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT. | Your medicines: (1) warfarin 5mg once daily [blood thinner — requires regular INR blood tests]. (2) pantoprazole 40mg before breakfast [acid-reducing medicine]. (3) tramadol 50mg every 6 hours as needed for pain [may cause drowsiness — max 4/day]. (4) Xarelto 20mg once daily with dinner [blood thinner]. Advice: do not ... | Hematology | Prescription | high |
1,476 | 76 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 76-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 |
1,477 | Rx: Tab atorvastatin 80mg QHS. Humalog per SSI. Tab escitalopram 10mg daily. Avoid NSAIDs. F/U 4 weeks with TSH, Free T4. | Your medicines: (1) atorvastatin 80mg at bedtime [high-dose cholesterol medicine]. (2) Humalog insulin before meals as directed [fast-acting insulin]. (3) escitalopram 10mg once daily [antidepressant/anxiety medicine]. Do not take anti-inflammatory pain medicines like ibuprofen (Advil) or naproxen (Aleve) as they can h... | Cardiology | Prescription | medium |
1,478 | 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 |
1,479 | Rx: Tab ondansetron 4mg Q8H PRN N/V. Tab lisinopril 10mg daily. Do not stop abruptly, taper as directed. F/U 6 weeks with LFTs. | Your medicines: (1) ondansetron (Zofran) 4mg every 8 hours as needed [anti-nausea medicine]. (2) lisinopril 10mg once daily [blood pressure medicine that also protects kidneys]. Do not suddenly stop this medicine — your doctor will gradually reduce the dose if needed. Come back in 6 weeks for liver function blood tests... | Cardiology | Prescription | medium |
1,480 | 55 y/o M with PMH of s/p TKR, anxiety, OSA on CPAP, GERD, admitted for NSTEMI. Troponin elevated confirming heart muscle damage. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on furosemide 40mg daily, amlodipine 10mg daily, metoprolol succinate 50mg daily. F/U surgery in... | A 55-year-old man with a history of prior knee replacement, anxiety, sleep apnea [uses a breathing machine at night], and acid reflux 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 stan... | Cardiology | Discharge Summary | high |
1,481 | MRI Lumbar Spine: Multilevel degenerative disc disease. Facet joint hypertrophy at L4-L5. Central canal stenosis at L3-L4. L5-S1 disc desiccation with mild bulge. | MRI of the lower back results: Multiple discs in the spine are showing wear and aging. The small joints in the spine at L4-L5 are enlarged from arthritis. The spinal canal is narrowed at L3-L4, which may be pressing on the nerves. At the L5-S1 level, the disc is dried out [worn] with a slight bulge, but not causing sig... | Orthopedics | Radiology Report | high |
1,482 | Delivery Note: G?P? at 40+0 weeks. Primary low-transverse C-section. Live male infant. APGAR 9/9. 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 9/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
1,483 | 91 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 91-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 |
1,484 | 40 y/o F with PMH of gout, BPH, admitted for STEMI. ECG showed ST elevation. Troponin markedly elevated. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on acetaminophen 650mg Q6H PRN, amoxicillin 500mg TID x 10 days. F/U PCP in 2 weeks. | A 40-year-old woman with a history of gout, and enlarged prostate 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. Be careful to prevent falls. Physical therapy and occupational th... | Cardiology | Discharge Summary | high |
1,485 | 52 y/o M with PMH of h/o TIA, h/o CVA, hypothyroidism, obesity (BMI 38), HLD, admitted for sepsis secondary to UTI. Blood cultures positive. Lactate elevated. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on metoprolol 25mg BID, ASA 81mg daily, furosemide 40mg daily, hyd... | A 52-year-old man with a history of history of mini-stroke, history of stroke, underactive thyroid, obesity, and high cholesterol was admitted for a serious blood infection from a urinary tract infection. Blood test showed bacteria in the blood. A marker of infection severity was high. They were treated according to st... | Infectious Disease | Discharge Summary | high |
1,486 | Procedure: Laparoscopic appendectomy. Pt 32 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 32-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 |
1,487 | 69 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 69-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 |
1,488 | 23 y/o F 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 23-year-old woman 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 ... | Emergency Medicine | Clinical Note | high |
1,489 | Rx: Tab furosemide 40mg daily. Tab warfarin 5mg daily. Avoid grapefruit juice. F/U 4 weeks with TSH, Free T4. | Your medicines: (1) furosemide (Lasix) 40mg once daily [water pill to remove extra fluid]. (2) warfarin 5mg once daily [blood thinner — requires regular INR blood tests]. Do not drink grapefruit juice as it interferes with this medication. Come back in 4 weeks for thyroid blood tests [TSH and Free T4] to check if the d... | Cardiology | Prescription | medium |
1,490 | CT Head without contrast: No mass effect. Chronic lacunar infarcts in bilateral basal ganglia. No midline shift. 4cm right subdural hematoma with 5mm midline shift. | 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. The brain is centered normally. 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 s... | Neurology | Radiology Report | high |
1,491 | 43 y/o F with PMH of s/p TKR, obesity (BMI 38), GERD, 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 lisinopril 20mg daily, timolol 0.5% OU BID, prednisone taper, omeprazole 20mg AC breakfast... | A 43-year-old woman with a history of prior knee replacement, obesity, and acid reflux 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 measures (no baths alone... | Cardiology | Discharge Summary | high |
1,492 | Procedure: Laparoscopic cholecystectomy. Pt 61 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 61-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 |
1,493 | Rx: albuterol MDI 2 puffs Q4-6H PRN. Tab amoxicillin 500mg TID x 10 days. Adv: weight bearing exercise, calcium/vit D supplementation. F/U 2 weeks. | Your medicines: (1) albuterol inhaler 2 puffs every 4-6 hours as needed [rescue inhaler for breathing]. (2) amoxicillin 500mg three times daily for 10 days [antibiotic — complete full course]. Advice: do weight-bearing exercises (walking, light weights) and take calcium and vitamin D for bone strength. Come back for a ... | Pulmonology | Prescription | medium |
1,494 | Procedure: R TKA. Pt 31 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 total knee replacement on the right for a 31-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 |
1,495 | HbA1c: 12.1% (H). FBS: 88 mg/dL (N). | Your diabetes blood test results: HbA1c is 12.1%, which is very high, meaning blood sugar has been dangerously uncontrolled (target is under 7%). Fasting blood sugar was 88, which is normal (normal is 70-100). Urgent medication adjustment needed. Very high risk of diabetes complications at this level. | Endocrinology | Lab Result | high |
1,496 | 70 y/o F 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 70-year-old woman 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 ... | Emergency Medicine | Clinical Note | high |
1,497 | 42 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 42-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 |
1,498 | 66 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 66-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 |
1,499 | 26 y/o M with PMH of s/p THR, asthma, admitted for appendicitis. CT confirmed. Taken to OR for laparoscopic appendectomy. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on metoprolol succinate 50mg daily, sertraline 50mg daily, rosuvastatin 10mg QHS, tramadol 50mg Q6H PRN pain, a... | A 26-year-old man with a history of prior hip replacement, and asthma was admitted for inflammation of the appendix. CT confirmed. Taken to OR for laparoscopic appendectomy. They were treated according to standard guidelines and improved. Write down your blood sugar readings in a log book and bring it to your next doct... | General Surgery | Discharge Summary | high |
1,500 | CBC: WBC 14.2 (H), Hgb 11.0 (L), Plt 365 (N). | Your blood count results: White blood cells are 14.2 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is low at 11.0, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 365, which is normal. | Hematology | Lab Result | high |
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