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1,601 | CXR PA: Left lower lobe consolidation. Cardiomegaly with CTR >0.5. Bilateral hilar lymphadenopathy. Elevated left hemidiaphragm. Moderate right pleural effusion. | Chest X-ray results: There is an area in the lower left lung that appears infected. The heart appears larger than normal. There are enlarged lymph nodes at the root of both lungs, which needs further evaluation. The left side of the breathing muscle [diaphragm] is sitting higher than normal. There is a moderate amount ... | Pulmonology | Radiology Report | high |
1,602 | Rx: Tab rosuvastatin 10mg QHS. Tab amoxicillin 500mg TID x 10 days. Tab metoprolol 25mg BID. Tab furosemide 40mg daily. Adv: wound care with daily dressing changes Adv: DASH diet, daily BP monitoring. F/U 1 month with repeat imaging. | Your medicines: (1) rosuvastatin 10mg at bedtime [cholesterol medicine]. (2) amoxicillin 500mg three times daily for 10 days [antibiotic — complete full course]. (3) metoprolol 25mg twice daily [slows heart rate and lowers blood pressure]. (4) furosemide (Lasix) 40mg once daily [water pill to remove extra fluid]. Advic... | Cardiology | Prescription | high |
1,603 | 44 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 44-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 |
1,604 | Rx: Tab azithromycin 500mg day 1 then 250mg x 4 days. Tab montelukast 10mg QHS. Tab Xarelto 20mg daily with dinner. Adv: smoking cessation, pulmonary rehab. F/U 6 weeks with LFTs. | Your medicines: (1) azithromycin: 500mg on day 1, then 250mg for the next 4 days [antibiotic]. (2) montelukast 10mg at bedtime [asthma/allergy medicine]. (3) Xarelto 20mg once daily with dinner [blood thinner]. Advice: stop smoking (ask about nicotine patches or gum) and attend lung rehabilitation program. Come back in... | Pulmonology | Prescription | medium |
1,605 | 28 y/o F 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 28-year-old woman 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 [... | Emergency Medicine | Clinical Note | high |
1,606 | 57 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 57-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 |
1,607 | 75 y/o F with PMH of GERD, DM1, ICD in situ, HFpEF, admitted for pyelonephritis. UA showed infection. Flank pain and fever. IV antibiotics started. Managed per protocol with improvement. BRAT diet x 48hrs, advance as tolerated. D/C on ciprofloxacin 500mg BID x 5 days, atorvastatin 40mg QHS, omeprazole 20mg AC breakfast... | A 75-year-old woman with a history of acid reflux, type 1 diabetes, implanted heart defibrillator, and heart failure with stiff heart muscle was admitted for a serious kidney infection. Urine test confirmed infection. Flank pain and fever. IV antibiotics started. They were treated according to standard guidelines and i... | Urology | Discharge Summary | high |
1,608 | 35 y/o M with PMH of BPH, DVT/PE on warfarin, CKD Stage 3, anemia, admitted for appendicitis. CT confirmed. Taken to OR for laparoscopic appendectomy. Managed per protocol with improvement. Strict NPO after midnight before procedure. D/C on tramadol 50mg Q6H PRN pain, ibuprofen 400mg Q6H PRN with food, rosuvastatin 10m... | A 35-year-old man with a history of enlarged prostate, blood clots [on blood thinner warfarin], moderate kidney disease, and low blood count [anemia] was admitted for inflammation of the appendix. CT confirmed. Taken to OR for laparoscopic appendectomy. They were treated according to standard guidelines and improved. D... | General Surgery | Discharge Summary | high |
1,609 | 23 y/o F 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 23-year-old woman 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... | Emergency Medicine | Clinical Note | high |
1,610 | 79 y/o M 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 79-year-old man 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 hea... | Emergency Medicine | Clinical Note | high |
1,611 | CT Head without contrast: Chronic lacunar infarcts in bilateral basal ganglia. No midline shift. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. 4cm right subdural hematoma with 5mm midline shift. | CT scan of the head results: There are signs of small old strokes in the deep parts of the brain. The brain is centered normally. There are aging-related changes in the brain's white matter from reduced blood flow to small vessels over time. There is a significant blood collection (4cm) on the right side between the br... | Neurology | Radiology Report | high |
1,612 | CT Head without contrast: Chronic lacunar infarcts in bilateral basal ganglia. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. 4cm right subdural hematoma with 5mm midline shift. | CT scan of the head results: There are signs of small old strokes in the deep parts of the brain. There are aging-related changes in the brain's white matter from reduced blood flow to small vessels over time. There is a significant blood collection (4cm) on the right side between the brain and skull, pushing the brain... | Neurology | Radiology Report | high |
1,613 | Enoxaparin 40mg SC daily until walking regularly. | Injection helps prevent clots until you are walking normally. | General | Medication Instruction | low |
1,614 | CBC: WBC 15.5 (H), Hgb 9.6 (L), Plt 32 (L). | Your blood count results: White blood cells are 15.5 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is low at 9.6, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 32, which is low — your blood may not clot properly, increasing ble... | Hematology | Lab Result | high |
1,615 | Rx: Tab acetaminophen 650mg Q6H PRN. Tab amoxicillin 500mg TID x 10 days. Tab furosemide 40mg daily. Adv: avoid alcohol, hepatotoxic drugs Adv: low salt diet, fluid restriction 1.5L/day. F/U 1 month with repeat imaging. | Your medicines: (1) Tylenol (acetaminophen) 650mg every 6 hours as needed [do not exceed 3000mg/day]. (2) amoxicillin 500mg three times daily for 10 days [antibiotic — complete full course]. (3) furosemide (Lasix) 40mg once daily [water pill to remove extra fluid]. Advice: do not drink alcohol and avoid medications tha... | Cardiology | Prescription | medium |
1,616 | 33 y/o M with PMH of hypothyroidism, SLE, h/o TIA, HFpEF, BPH, 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 escitalopram 10mg daily, hydroxychloroquine 200mg BID. F/U GI in 1 week. | A 33-year-old man with a history of underactive thyroid, lupus, history of mini-stroke, heart failure with stiff heart muscle, and enlarged prostate 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 i... | Cardiology | Discharge Summary | high |
1,617 | CBC: WBC 19.0 (H), Hgb 17.3 (H), Plt 268 (N). | Your blood count results: White blood cells are 19.0 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is elevated at 17.3. Platelets are 268, which is normal. | Hematology | Lab Result | high |
1,618 | 54 y/o M with PMH of CKD Stage 4, CAD, admitted for acute pancreatitis. Lipase markedly elevated. CT showed peripancreatic inflammation. Managed per protocol with improvement. Compression stockings when ambulating. D/C on amlodipine 5mg daily, carvedilol 12.5mg BID, ferrous sulfate 325mg BID, gabapentin 300mg TID, pant... | A 54-year-old man with a history of advanced kidney disease, and coronary artery disease [heart artery blockages] was admitted for severe inflammation of the pancreas. A pancreas enzyme was very high. CT scan showed peripancreatic inflammation. They were treated according to standard guidelines and improved. Wear compr... | Gastroenterology | Discharge Summary | high |
1,619 | Rx: Tab metformin 500mg BID. Tab hydroxychloroquine 200mg BID. Adv: low salt low sugar diet, regular exercise Adv: SMBG BID, diabetic diet. F/U 1 month with repeat imaging. | Your medicines: (1) metformin 500mg twice daily with meals [blood sugar medicine]. (2) hydroxychloroquine 200mg twice daily [immune-modulating medicine — eye exams needed]. Advice: eat less salt and sugar, and exercise at least 30 minutes most days Advice: check your blood sugar twice daily and follow a diabetes-friend... | Pediatrics | Prescription | medium |
1,620 | CT Head without contrast: No midline shift. Paranasal sinuses clear. Subarachnoid hemorrhage in bilateral sylvian fissures. | CT scan of the head results: The brain is centered normally. The sinuses are clear with no infection. There is bleeding around the brain surface, particularly in the grooves on both sides. | Neurology | Radiology Report | high |
1,621 | BMP: Na 145 (N), K 3.2 (L), BUN 14, Cr 1.9 (H), Glucose 68. | Your blood chemistry results: Sodium is normal at 145. Potassium is low at 3.2 — may cause muscle weakness and heart rhythm issues. Creatinine is elevated at 1.9 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 68 (low). | Nephrology | Lab Result | high |
1,622 | 33 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 33-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 |
1,623 | HbA1c: 10.8% (H). FBS: 280 mg/dL (H). | Your diabetes blood test results: HbA1c is 10.8%, which is very high, meaning blood sugar has been dangerously uncontrolled (target is under 7%). Fasting blood sugar was 280, which is high (normal is 70-100). Urgent medication adjustment needed. Very high risk of diabetes complications at this level. | Endocrinology | Lab Result | high |
1,624 | 43 y/o M with PMH of DM1, PPM in situ, h/o TIA, admitted for NSTEMI. Troponin elevated confirming heart muscle damage. Managed per protocol with improvement. Low potassium diet. D/C on glipizide 5mg BID AC, losartan 50mg daily, ASA 81mg daily. F/U endocrine in 1 week. | A 43-year-old man with a history of type 1 diabetes, implanted pacemaker, and history of mini-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. Avo... | Cardiology | Discharge Summary | high |
1,625 | HbA1c: 5.1% (N). FBS: 327 mg/dL (H). | Your diabetes blood test results: HbA1c is 5.1%, which is normal — you do not have diabetes. Fasting blood sugar was 327, which is high (normal is 70-100). No diabetes treatment needed. Continue healthy lifestyle. | Endocrinology | Lab Result | high |
1,626 | 62 y/o M 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 62-year-old man 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: appen... | Emergency Medicine | Clinical Note | high |
1,627 | 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 |
1,628 | 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 | low |
1,629 | CT Head without contrast: No mass effect. No midline shift. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. | CT scan of the head results: There are no tumors or masses pushing on the brain. The brain is centered normally. There are aging-related changes in the brain's white matter from reduced blood flow to small vessels over time. | Neurology | Radiology Report | high |
1,630 | Rx: Tab ibuprofen 400mg Q6H PRN with food. Tab tramadol 50mg Q6H PRN pain. Tab pregabalin 75mg BID. Tab ASA 81mg daily. Adv: smoking cessation, pulmonary rehab Adv: SMBG BID, diabetic diet. F/U 1 month with repeat imaging. | Your medicines: (1) ibuprofen 400mg every 6 hours as needed with food [anti-inflammatory pain reliever]. (2) tramadol 50mg every 6 hours as needed for pain [may cause drowsiness — max 4/day]. (3) pregabalin 75mg twice daily [nerve pain medicine]. (4) baby aspirin 81mg once daily [prevents blood clots]. Advice: stop smo... | General | Prescription | high |
1,631 | 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 | medium |
1,632 | Rx: Lantus 20U QHS. Tab amlodipine 5mg daily. Tab timolol 0.5% OU BID. Adv: smoking cessation, pulmonary rehab Adv: avoid alcohol, hepatotoxic drugs. F/U 1 month with repeat imaging. | Your medicines: (1) Lantus insulin 20 units at bedtime [long-acting insulin]. (2) amlodipine 5mg once daily [blood pressure medicine]. (3) timolol eye drops in both eyes twice daily [lowers eye pressure for glaucoma]. Advice: stop smoking (ask about nicotine patches or gum) and attend lung rehabilitation program Advice... | Cardiology | Prescription | medium |
1,633 | 41 y/o M with PMH of PPM in situ, obesity (BMI 38), admitted for cellulitis L lower extremity. Area was red, warm, and swollen. Marked with pen to track spread. Managed per protocol with improvement. Wound care: daily dressing changes with wet-to-dry gauze. D/C on ibuprofen 400mg Q6H PRN with food, atorvastatin 80mg QH... | A 41-year-old man with a history of implanted pacemaker, and obesity 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. Change the wound dressing daily: wet the gauze with saline, place on ... | Infectious Disease | Discharge Summary | high |
1,634 | 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 |
1,635 | 82 y/o M with PMH of PAD, DM1, s/p CABG, CKD Stage 4, admitted for TIA. Symptoms resolved. MRI negative for infarct. Managed per protocol with improvement. BRAT diet x 48hrs, advance as tolerated. D/C on azithromycin 500mg day 1 then 250mg x 4 days, Lantus 20U QHS, entresto 49/51mg BID. F/U PCP in 1 week. | A 82-year-old man with a history of poor blood flow in the legs [peripheral artery disease], type 1 diabetes, prior heart bypass surgery, and advanced kidney disease was admitted for a mini-stroke [temporary loss of brain function]. Symptoms resolved. MRI negative for infarct. They were treated according to standard gu... | Neurology | Discharge Summary | high |
1,636 | CXR PA: Right lower lobe consolidation. ET tube 3cm above carina. Osseous structures intact. Sternotomy wires intact. Cardiomegaly with CTR >0.5. | Chest X-ray results: There is an area in the lower right lung that appears infected, suggesting pneumonia. The breathing tube is in good position. The bones look normal with no fractures. The wires from prior heart surgery are intact. The heart appears larger than normal. | Pulmonology | Radiology Report | high |
1,637 | CXR PA: No pneumothorax. Right lower lobe consolidation. Widened mediastinum. No cardiomegaly. Bilateral pleural effusions. | Chest X-ray results: There is no collapsed lung. There is an area in the lower right lung that appears infected, suggesting pneumonia. The space between the lungs appears wider than normal, which needs further evaluation. The heart is a normal size. There is fluid collecting around both lungs. | Pulmonology | Radiology Report | high |
1,638 | Rx: Tab metoprolol 25mg BID. Tab ciprofloxacin 500mg BID x 5 days. Tab ASA 81mg daily. Tab metoprolol succinate 50mg daily. Adv: high fiber diet, adequate hydration. F/U 1 week with wound check. | Your medicines: (1) metoprolol 25mg twice daily [slows heart rate and lowers blood pressure]. (2) ciprofloxacin 500mg twice daily for 5 days [antibiotic — avoid dairy within 2 hours]. (3) baby aspirin 81mg once daily [prevents blood clots]. (4) metoprolol 50mg once daily [heart rate and blood pressure medicine]. Advice... | Cardiology | Prescription | high |
1,639 | US Abdomen: Spleen 11cm, normal. GB sludge, no stones. Left kidney 8cm, cortical thinning consistent with CKD. | Abdominal ultrasound results: The spleen is a normal size. The gallbladder contains thickened bile [sludge] but no stones. Left kidney is small with thin outer layer, consistent with chronic kidney disease. | Gastroenterology | Radiology Report | high |
1,640 | 57 y/o M with PMH of gout, DM2, GERD, admitted for acute CHF exacerbation. BNP elevated. CXR showed pulmonary edema. Managed per protocol with improvement. Seizure precautions, do not drive x 6 months. D/C on ASA 81mg daily, pantoprazole 40mg AC breakfast. F/U endocrine in 1 week. | A 57-year-old man with a history of gout, type 2 diabetes, and acid reflux 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. Take seizure safety measures (no baths alone, no heights). Do not dri... | Cardiology | Discharge Summary | high |
1,641 | 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 |
1,642 | 83 y/o F with PMH of s/p THR, CAD, CKD Stage 3, cirrhosis, osteoporosis, admitted for acute stroke (CVA). CT showed acute ischemic infarct. tPA administered. Managed per protocol with improvement. Head injury precautions x 48hrs. D/C on atorvastatin 80mg QHS, methotrexate 15mg weekly, Spiriva 18mcg daily, azithromycin ... | A 83-year-old woman with a history of prior hip replacement, coronary artery disease [heart artery blockages], moderate kidney disease, liver scarring [cirrhosis], and weak bones [osteoporosis] was admitted for a stroke [blocked blood vessel in the brain]. CT scan showed acute ischemic infarct. clot-dissolving medicine... | Neurology | Discharge Summary | high |
1,643 | Delivery Note: G?P? at 40+0 weeks. SVD. Live male infant. APGAR 8/9. EBL within expected limits. Mother stable. | Birth summary: pregnancy reached about 40+0 weeks gestation. The baby was delivered by normal vaginal delivery. The newborn is a healthy male. APGAR scores were 8/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
1,644 | 87 y/o M with PMH of asthma, OSA on CPAP, DM2, obesity (BMI 38), admitted for hypertensive urgency. BP 210/120. IV medications started to lower gradually. Managed per protocol with improvement. Head injury precautions x 48hrs. D/C on Spiriva 18mcg daily, Dulcolax 10mg QHS PRN, empagliflozin 10mg daily, amlodipine 10mg ... | A 87-year-old man with a history of asthma, sleep apnea [uses a breathing machine at night], type 2 diabetes, and obesity 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. Watch for: worsening headach... | Cardiology | Discharge Summary | high |
1,645 | Delivery Note: G?P? at 38+2 weeks. SVD. Live male infant. APGAR 9/9. 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 9/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
1,646 | Rx: Tab rosuvastatin 10mg QHS. Tab spironolactone 25mg daily. Tab metoprolol succinate 50mg daily. Adv: elevate affected limb, compression stockings. F/U 6 weeks with LFTs. | Your medicines: (1) rosuvastatin 10mg at bedtime [cholesterol medicine]. (2) spironolactone 25mg once daily [heart-protecting water pill]. (3) metoprolol 50mg once daily [heart rate and blood pressure medicine]. Advice: keep the affected leg elevated when resting and wear compression stockings. Come back in 6 weeks for... | Cardiology | Prescription | medium |
1,647 | Rx: Tab pantoprazole 40mg AC breakfast. Tab lisinopril 20mg daily. Tab amoxicillin 500mg TID x 10 days. Adv: avoid alcohol, hepatotoxic drugs. F/U PCP in 1 week for BP recheck. | Your medicines: (1) pantoprazole 40mg before breakfast [acid-reducing medicine]. (2) lisinopril 20mg once daily [blood pressure medicine]. (3) amoxicillin 500mg three times daily for 10 days [antibiotic — complete full course]. Advice: do not drink alcohol and avoid medications that can harm the liver (including acetam... | Cardiology | Prescription | medium |
1,648 | LFTs: AST 201 (H), ALT 137 (H), ALP 49, T.Bili 1.7 (H), Albumin 3.5. | Your liver blood test results: Liver enzymes (AST 201, ALT 137) are moderately elevated, indicating liver irritation (normal is under 40). Bilirubin is mildly elevated at 1.7. Albumin is normal at 3.5. | Gastroenterology | Lab Result | high |
1,649 | Rx: Tab gabapentin 300mg TID. Tab ondansetron 4mg Q8H PRN N/V. albuterol MDI 2 puffs Q4-6H PRN. Tab ibuprofen 400mg Q6H PRN with food. Tab metformin 500mg BID. Adv: low potassium diet. F/U 1 month with repeat imaging. | Your medicines: (1) gabapentin 300mg three times daily [nerve pain medicine — may cause drowsiness]. (2) ondansetron (Zofran) 4mg every 8 hours as needed [anti-nausea medicine]. (3) albuterol inhaler 2 puffs every 4-6 hours as needed [rescue inhaler for breathing]. (4) ibuprofen 400mg every 6 hours as needed with food ... | General | Prescription | high |
1,650 | 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 |
1,651 | CXR PA: Clear lung fields bilaterally. Pacemaker leads in appropriate position. Right lower lobe consolidation. | Chest X-ray results: Both lungs look clear with no problems. The pacemaker wires are in the correct position. There is an area in the lower right lung that appears infected, suggesting pneumonia. | Pulmonology | Radiology Report | high |
1,652 | 56 y/o F 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 56-year-old woman 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 [... | Emergency Medicine | Clinical Note | high |
1,653 | 39 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 39-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 |
1,654 | Rx: Tab ASA 81mg daily. Tab methotrexate 15mg weekly. albuterol MDI 2 puffs Q4-6H PRN. Tab pregabalin 75mg BID. Avoid grapefruit juice. F/U PCP in 1 week for BP recheck. | Your medicines: (1) baby aspirin 81mg once daily [prevents blood clots]. (2) methotrexate 15mg once weekly [immune-suppressing medicine for arthritis — requires monitoring]. (3) albuterol inhaler 2 puffs every 4-6 hours as needed [rescue inhaler for breathing]. (4) pregabalin 75mg twice daily [nerve pain medicine]. Do ... | Cardiology | Prescription | high |
1,655 | 67 y/o M with PMH of DM2, anxiety, gout, ICD in situ, admitted for DKA. Blood sugar >500. pH 7.1. Anion gap elevated. Managed per protocol with improvement. Compression stockings when ambulating. D/C on ferrous sulfate 325mg BID, ASA 81mg daily, clopidogrel 75mg daily, omeprazole 20mg AC breakfast. F/U nephrology in 5 ... | A 67-year-old man with a history of type 2 diabetes, anxiety, gout, and implanted heart defibrillator was admitted for diabetic ketoacidosis [dangerously high blood sugar with acid buildup]. Blood sugar >500. blood became dangerously acidic. Anion gap elevated. They were treated according to standard guidelines and imp... | Endocrinology | Discharge Summary | high |
1,656 | 42 y/o M with PMH of DM1, h/o CVA, depression, GERD, PAD, admitted for lower GI bleeding. Bright red blood per rectum. Hemoglobin dropping. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on latanoprost 0.005% OU QHS, hydroxychloroquine 200mg BID, Humalog per SSI, metoprol... | A 42-year-old man with a history of type 1 diabetes, history of stroke, depression, acid reflux, and poor blood flow in the legs [peripheral artery disease] was admitted for bleeding from the large intestine. Bright red blood per rectum. Hemoglobin dropping. They were treated according to standard guidelines and improv... | Gastroenterology | Discharge Summary | high |
1,657 | 30 y/o M presenting to ED with acute onset pleuritic CP, SOB, R calf swelling x 3 days. Vitals: BP 132/88, HR 112, RR 24, O2 91% on RA. D-dimer elevated. CTA chest: bilateral PE with RV strain. US R LE: popliteal DVT. Dx: Bilateral PE with DVT. Heparin drip started. Consider catheter-directed thrombolysis given RV stra... | A 30-year-old man came to the emergency room with sudden chest pain that worsens with breathing, shortness of breath, and right calf swelling for 3 days. Vital signs: blood pressure normal, heart rate fast, breathing rapid, oxygen low at 91%. A blood clot screening test was positive. CT scan confirmed blood clots in bo... | Emergency Medicine | Clinical Note | high |
1,658 | CT Head without contrast: No acute intracranial hemorrhage. Mild generalized cerebral atrophy appropriate for age. Subarachnoid hemorrhage in bilateral sylvian fissures. | CT scan of the head results: There is no bleeding in the brain. There is mild brain shrinkage, which is normal for your age. There is bleeding around the brain surface, particularly in the grooves on both sides. | Neurology | Radiology Report | high |
1,659 | Rx: Tab tramadol 50mg Q6H PRN pain. Tab montelukast 10mg QHS. Tab Eliquis 5mg BID. Tab hydroxychloroquine 200mg BID. Tab Augmentin 875/125 BID x 7 days. Avoid NSAIDs Adv: avoid alcohol, hepatotoxic drugs. F/U 1 month with repeat imaging. | Your medicines: (1) tramadol 50mg every 6 hours as needed for pain [may cause drowsiness — max 4/day]. (2) montelukast 10mg at bedtime [asthma/allergy medicine]. (3) Eliquis 5mg twice daily [blood thinner]. (4) hydroxychloroquine 200mg twice daily [immune-modulating medicine — eye exams needed]. (5) Augmentin 875mg twi... | Pulmonology | Prescription | high |
1,660 | Rx: Tab ondansetron 4mg Q8H PRN N/V. Tab clopidogrel 75mg daily. Tab carvedilol 12.5mg BID. Adv: DASH diet, daily BP monitoring. F/U 1 week with CBC, CMP. | Your medicines: (1) ondansetron (Zofran) 4mg every 8 hours as needed [anti-nausea medicine]. (2) Plavix (clopidogrel) 75mg once daily [blood thinner]. (3) carvedilol 12.5mg twice daily [heart medicine]. Advice: follow the DASH diet (rich in fruits, vegetables, lean protein, low in salt) and check blood pressure at home... | Cardiology | Prescription | medium |
1,661 | Rx: Tab acetaminophen 650mg Q6H PRN. Tab Eliquis 5mg BID. Tab levothyroxine 75mcg daily on empty stomach. Tab clopidogrel 75mg daily. Do not stop abruptly, taper as directed. F/U 4 weeks with TSH, Free T4. | Your medicines: (1) Tylenol (acetaminophen) 650mg every 6 hours as needed [do not exceed 3000mg/day]. (2) Eliquis 5mg twice daily [blood thinner]. (3) levothyroxine 75mcg on empty stomach 30 min before breakfast [thyroid medicine]. (4) Plavix (clopidogrel) 75mg once daily [blood thinner]. Do not suddenly stop this medi... | Cardiology | Prescription | high |
1,662 | Rx: Tab pregabalin 75mg BID. Tab methotrexate 15mg weekly. Tab furosemide 40mg BID. Avoid grapefruit juice. F/U 2 weeks with INR. | Your medicines: (1) pregabalin 75mg twice daily [nerve pain medicine]. (2) methotrexate 15mg once weekly [immune-suppressing medicine for arthritis — requires monitoring]. (3) furosemide (Lasix) 40mg twice daily [water pill]. Do not drink grapefruit juice as it interferes with this medication. Come back in 2 weeks for ... | Cardiology | Prescription | medium |
1,663 | 59 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 59-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 |
1,664 | 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 |
1,665 | Rx: Tab metformin 1000mg BID. Tab tramadol 50mg Q6H PRN pain. prednisone taper. Adv: elevate affected limb, compression stockings. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT. | Your medicines: (1) metformin 1000mg twice daily with meals [blood sugar medicine]. (2) tramadol 50mg every 6 hours as needed for pain [may cause drowsiness — max 4/day]. (3) prednisone steroid — dose gradually decreases as directed [do not stop suddenly]. Advice: keep the affected leg elevated when resting and wear co... | Endocrinology | Prescription | medium |
1,666 | Rx: Tab amoxicillin 500mg TID x 10 days. Tab metoprolol 25mg BID. Do not stop abruptly, taper as directed. F/U 2 weeks. | Your medicines: (1) amoxicillin 500mg three times daily for 10 days [antibiotic — complete full course]. (2) metoprolol 25mg twice daily [slows heart rate and lowers blood pressure]. Do not suddenly stop this medicine — your doctor will gradually reduce the dose if needed. Come back for a check-up in 2 weeks. | Cardiology | Prescription | medium |
1,667 | 23 y/o F with PMH of CKD Stage 3, Parkinson's disease, RA on MTX, admitted for acute kidney injury. Creatinine rose sharply from baseline. Managed per protocol with improvement. Diabetic diet, SMBG BID. D/C on metoprolol succinate 50mg daily, levothyroxine 75mcg daily on empty stomach. F/U endocrine in 1 week. | A 23-year-old woman with a history of moderate kidney disease, Parkinson's disease, and rheumatoid arthritis [on immune-suppressing medicine] was admitted for sudden worsening of kidney function. Kidney waste products rose sharply from baseline. They were treated according to standard guidelines and improved. Follow a ... | Nephrology | Discharge Summary | high |
1,668 | HbA1c: 11.2% (H). FBS: 291 mg/dL (H). | Your diabetes blood test results: HbA1c is 11.2%, which is very high, meaning blood sugar has been dangerously uncontrolled (target is under 7%). Fasting blood sugar was 291, which is high (normal is 70-100). Urgent medication adjustment needed. Very high risk of diabetes complications at this level. | Endocrinology | Lab Result | high |
1,669 | Rx: Tab hydroxychloroquine 200mg BID. albuterol MDI 2 puffs Q4-6H PRN. Tab tramadol 50mg Q6H PRN pain. Tab Xarelto 20mg daily with dinner. Tab lisinopril 20mg daily. Adv: wound care with daily dressing changes. F/U 4 weeks with TSH, Free T4. | Your medicines: (1) hydroxychloroquine 200mg twice daily [immune-modulating medicine — eye exams needed]. (2) albuterol inhaler 2 puffs every 4-6 hours as needed [rescue inhaler for breathing]. (3) tramadol 50mg every 6 hours as needed for pain [may cause drowsiness — max 4/day]. (4) Xarelto 20mg once daily with dinner... | Cardiology | Prescription | high |
1,670 | 42 y/o F with PMH of asthma, anxiety, OA, HFpEF, h/o TIA, admitted for cellulitis R lower extremity. Leg was red, swollen, and warm. IV antibiotics started. Managed per protocol with improvement. Low potassium diet. D/C on furosemide 40mg BID, gabapentin 300mg TID, losartan 50mg daily. F/U endocrine in 1 week. | A 42-year-old woman with a history of asthma, anxiety, arthritis [osteoarthritis], heart failure with stiff heart muscle, and history of mini-stroke 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... | Infectious Disease | Discharge Summary | high |
1,671 | Rx: Tab spironolactone 25mg daily. Tab calcium + vitamin D 600/400 daily. Adv: wound care with daily dressing changes. F/U 2 weeks with INR. | Your medicines: (1) spironolactone 25mg once daily [heart-protecting water pill]. (2) calcium plus vitamin D once daily [bone strengthening]. Advice: change the wound dressing once daily — clean with saline, apply ointment, cover with fresh bandage. Come back in 2 weeks for a blood thinner level check [INR]. | Cardiology | Prescription | medium |
1,672 | 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 |
1,673 | CXR PA: Elevated left hemidiaphragm. NG tube tip in stomach. Pacemaker leads in appropriate position. | Chest X-ray results: The left side of the breathing muscle [diaphragm] is sitting higher than normal. The feeding/drainage tube tip is correctly positioned in the stomach. The pacemaker wires are in the correct position. | Pulmonology | Radiology Report | high |
1,674 | 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 |
1,675 | Rx: Tab metoprolol succinate 50mg daily. Tab atorvastatin 40mg QHS. Tab lisinopril 20mg daily. Tab entresto 49/51mg BID. Adv: low potassium diet Adv: SMBG BID, diabetic diet. F/U 1 week with wound check. | Your medicines: (1) metoprolol 50mg once daily [heart rate and blood pressure medicine]. (2) atorvastatin 40mg at bedtime [cholesterol medicine]. (3) lisinopril 20mg once daily [blood pressure medicine]. (4) Entresto 49/51mg twice daily [heart failure medicine]. Advice: avoid high-potassium foods like bananas, oranges,... | Cardiology | Prescription | high |
1,676 | Rx: Tab atorvastatin 80mg QHS. Tab Dulcolax 10mg QHS PRN. Tab Augmentin 875/125 BID x 7 days. Adv: smoking cessation, pulmonary rehab. F/U 2 weeks. | Your medicines: (1) atorvastatin 80mg at bedtime [high-dose cholesterol medicine]. (2) Dulcolax 10mg at bedtime as needed [for constipation]. (3) Augmentin 875mg twice daily for 7 days [antibiotic]. Advice: stop smoking (ask about nicotine patches or gum) and attend lung rehabilitation program. Come back for a check-up... | Cardiology | Prescription | medium |
1,677 | Procedure: ORIF L distal radius. Pt 53 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 53-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 |
1,678 | Lipid panel: TC 157, LDL 97, HDL 68, TG 204. | Your cholesterol results: Total cholesterol is 157. LDL (bad cholesterol) is at goal (97). HDL (good cholesterol) is good at 68. Triglycerides are high at 204. | Cardiology | Lab Result | high |
1,679 | US Abdomen: Moderate right hydronephrosis. Left kidney 8cm, cortical thinning consistent with CKD. GB wall thickening with stones, positive Murphy's sign. GB sludge, no stones. Simple renal cysts bilaterally. | Abdominal ultrasound results: The right kidney is swollen because urine is backing up [hydronephrosis], possibly from a blockage. Left kidney is small with thin outer layer, consistent with chronic kidney disease. The gallbladder wall is thickened and gallstones are present — pressing on the gallbladder area caused pai... | Gastroenterology | Radiology Report | high |
1,680 | CT Head without contrast: Chronic lacunar infarcts in bilateral basal ganglia. Subarachnoid hemorrhage in bilateral sylvian fissures. No mass effect. Mild generalized cerebral atrophy appropriate for age. | CT scan of the head results: There are signs of small old strokes in the deep parts of the brain. There is bleeding around the brain surface, particularly in the grooves on both sides. There are no tumors or masses pushing on the brain. There is mild brain shrinkage, which is normal for your age. | Neurology | Radiology Report | high |
1,681 | BMP: Na 127 (L), K 6.7 (H), BUN 86, Cr 1.6 (H), Glucose 297. | Your blood chemistry results: Sodium is low at 127 (normal 136-145), meaning too much water in your body. Potassium is dangerously high at 6.7 (normal 3.5-5.0) — this can affect your heart and needs immediate treatment. Creatinine is elevated at 1.6 (normal under 1.2), indicating your kidneys are not filtering well. Bl... | Nephrology | Lab Result | high |
1,682 | Rx: Tab ferrous sulfate 325mg BID. Tab pregabalin 75mg BID. Tab acetaminophen 650mg Q6H PRN. Tab amoxicillin 500mg TID x 10 days. Avoid NSAIDs Adv: SMBG BID, diabetic diet. F/U 1 week with wound check. | Your medicines: (1) iron supplement 325mg twice daily [for low blood count — take with vitamin C]. (2) pregabalin 75mg twice daily [nerve pain medicine]. (3) Tylenol (acetaminophen) 650mg every 6 hours as needed [do not exceed 3000mg/day]. (4) amoxicillin 500mg three times daily for 10 days [antibiotic — complete full ... | General | Prescription | high |
1,683 | 56 y/o M with PMH of SLE, HLD, OA, admitted for hypertensive urgency. BP 210/120. IV medications started to lower gradually. Managed per protocol with improvement. Seizure precautions, do not drive x 6 months. D/C on potassium chloride 20mEq daily, atorvastatin 80mg QHS, empagliflozin 10mg daily. F/U surgery in 2 weeks... | A 56-year-old man with a history of lupus, high cholesterol, and arthritis [osteoarthritis] 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. Take seizure safety measures (no baths alone, no heights).... | Cardiology | Discharge Summary | high |
1,684 | Procedure: TURP for BPH. 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 scope surgery to trim enlarged prostate tissue 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. | Urology | Procedure Note | high |
1,685 | Rx: Tab furosemide 40mg daily. Tab Augmentin 875/125 BID x 7 days. Tab ondansetron 4mg Q8H PRN N/V. Tab amlodipine 10mg daily. Adv: elevate affected limb, compression stockings. F/U INR in 3 days. | Your medicines: (1) furosemide (Lasix) 40mg once daily [water pill to remove extra fluid]. (2) Augmentin 875mg twice daily for 7 days [antibiotic]. (3) ondansetron (Zofran) 4mg every 8 hours as needed [anti-nausea medicine]. (4) amlodipine 10mg once daily [blood pressure medicine]. Advice: keep the affected leg elevate... | Cardiology | Prescription | high |
1,686 | 37 y/o M with PMH of hypothyroidism, A-fib, h/o CVA, admitted for NSTEMI. Troponin elevated confirming heart muscle damage. Managed per protocol with improvement. Smoking cessation counseling provided. D/C on clopidogrel 75mg daily, lisinopril 20mg daily, atorvastatin 40mg QHS, carvedilol 12.5mg BID, levothyroxine 75mc... | A 37-year-old man with a history of underactive thyroid, irregular heartbeat [atrial fibrillation], 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 guideli... | Cardiology | Discharge Summary | high |
1,687 | BMP: Na 149 (H), K 4.4 (N), BUN 83, Cr 1.8 (H), Glucose 349. | Your blood chemistry results: Sodium is high at 149, meaning you may be dehydrated. Potassium is normal at 4.4. Creatinine is elevated at 1.8 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 349 (high). | Nephrology | Lab Result | high |
1,688 | BMP: Na 139 (N), K 4.5 (N), BUN 21, Cr 2.1 (H), Glucose 397. | Your blood chemistry results: Sodium is normal at 139. Potassium is normal at 4.5. Creatinine is elevated at 2.1 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 397 (high). | Nephrology | Lab Result | high |
1,689 | Procedure: Laparoscopic appendectomy. Pt 36 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 36-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 |
1,690 | Thyroid panel: TSH 4.78 (H), Free T4 2.1. | Your thyroid test results: TSH is elevated at 4.78 (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 |
1,691 | Thyroid panel: TSH 4.59 (H), Free T4 0.9. | Your thyroid test results: TSH is elevated at 4.59 (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 |
1,692 | HbA1c: 7.8% (H). FBS: 204 mg/dL (H). | Your diabetes blood test results: HbA1c is 7.8%, 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 204, which is high (normal is 70-100). Your diabetes medicines may need adjustment. Discuss with your doctor. | Endocrinology | Lab Result | high |
1,693 | 91 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 91-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 |
1,694 | CT Head without contrast: 4cm right subdural hematoma with 5mm midline shift. Acute ischemic infarct in R MCA territory. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. | 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 a new stroke affecting the right side of the brain, in the area supplied by the middle cerebral artery. There are aging-related changes ... | Neurology | Radiology Report | high |
1,695 | 52 y/o M with PMH of cirrhosis, anemia, admitted for fall with hip fracture. X-ray confirmed femoral neck fracture. Orthopedics consulted. Managed per protocol with improvement. Daily weights, 1.5L fluid restriction, low sodium diet. D/C on ASA 81mg daily, furosemide 40mg daily. F/U endocrine in 1 week. | A 52-year-old man with a history of liver scarring [cirrhosis], and low blood count [anemia] 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. Weigh yourself every morning before eating. Limit fluids t... | Orthopedics | Discharge Summary | high |
1,696 | Rx: Tab gabapentin 300mg TID. Tab Eliquis 5mg BID. Tab Dulcolax 10mg QHS PRN. Tab timolol 0.5% OU BID. Adv: low potassium diet Adv: smoking cessation, pulmonary rehab. F/U INR in 3 days. | Your medicines: (1) gabapentin 300mg three times daily [nerve pain medicine — may cause drowsiness]. (2) Eliquis 5mg twice daily [blood thinner]. (3) Dulcolax 10mg at bedtime as needed [for constipation]. (4) timolol eye drops in both eyes twice daily [lowers eye pressure for glaucoma]. Advice: avoid high-potassium foo... | Neurology | Prescription | high |
1,697 | Lipid panel: TC 239, LDL 194, HDL 72, TG 203. | Your cholesterol results: Total cholesterol is 239. LDL (bad cholesterol) is very high at 194 (goal under 100), significantly increasing heart disease risk. HDL (good cholesterol) is good at 72. Triglycerides are high at 203. | Cardiology | Lab Result | high |
1,698 | 35 y/o F with PMH of cirrhosis, s/p TKR, admitted for cellulitis R lower extremity. Leg was red, swollen, and warm. IV antibiotics started. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on hydroxychloroquine 200mg BID, carvedilol 12.5mg BID. F/U wound care in 3 days. | A 35-year-old woman with a history of liver scarring [cirrhosis], and prior knee replacement 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. Use the breathing exercise device every hour while awa... | Infectious Disease | Discharge Summary | high |
1,699 | MRI Lumbar Spine: L5-S1 disc desiccation with mild bulge. Facet joint hypertrophy at L4-L5. | 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. The small joints in the spine at L4-L5 are enlarged from arthritis. | Orthopedics | Radiology Report | high |
1,700 | 63 y/o M with PMH of HFpEF, CKD Stage 3, admitted for sepsis secondary to cellulitis. Blood cultures drawn. IV antibiotics started emergently. Managed per protocol with improvement. Daily weights, 1.5L fluid restriction, low sodium diet. D/C on pregabalin 75mg BID, ASA 81mg daily. F/U surgery in 10 days. | A 63-year-old man with a history of heart failure with stiff heart muscle, and moderate kidney disease was admitted for a serious blood infection from a skin infection. Blood cultures drawn. IV antibiotics started emergently. They were treated according to standard guidelines and improved. Weigh yourself every morning ... | Infectious Disease | Discharge Summary | high |
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