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1,701
Rx: Tab rosuvastatin 10mg QHS. Tab furosemide 40mg daily. Humalog per SSI. Tab amoxicillin 500mg TID x 10 days. Tab ibuprofen 400mg Q6H PRN with food. Adv: DASH diet, daily BP monitoring Adv: smoking cessation, pulmonary rehab. F/U 2 weeks with INR.
Your medicines: (1) rosuvastatin 10mg at bedtime [cholesterol medicine]. (2) furosemide (Lasix) 40mg once daily [water pill to remove extra fluid]. (3) Humalog insulin before meals as directed [fast-acting insulin]. (4) amoxicillin 500mg three times daily for 10 days [antibiotic — complete full course]. (5) ibuprofen 4...
Cardiology
Prescription
high
1,702
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
1,703
CT Head without contrast: Chronic lacunar infarcts in bilateral basal ganglia. No mass effect. Subarachnoid hemorrhage in bilateral sylvian fissures. Mild generalized cerebral atrophy appropriate for age. 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 no tumors or masses pushing on the brain. There is bleeding around the brain surface, particularly in the grooves on both sides. There is mild brain shrinkage, which is normal for your age. There is a significant...
Neurology
Radiology Report
high
1,704
Enoxaparin 40mg SC daily until walking regularly.
Injection helps prevent clots until you are walking normally.
General
Medication Instruction
low
1,705
68 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 68-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
1,706
65 y/o F with PMH of s/p TKR, OA, admitted for alcohol withdrawal. CIWA protocol initiated. Lorazepam given as needed. Managed per protocol with improvement. Seizure precautions, do not drive x 6 months. D/C on potassium chloride 20mEq daily, escitalopram 10mg daily, Augmentin 875/125 BID x 7 days. F/U surgery in 10 da...
A 65-year-old woman with a history of prior knee replacement, and arthritis [osteoarthritis] was admitted for withdrawal symptoms after stopping alcohol. CIWA protocol initiated. Lorazepam given as needed. They were treated according to standard guidelines and improved. Take seizure safety measures (no baths alone, no ...
Psychiatry
Discharge Summary
high
1,707
Rx: Tab gabapentin 300mg TID. Tab metoprolol succinate 50mg daily. Tab sertraline 50mg daily. Do not stop abruptly, taper as directed Adv: low potassium diet. F/U 1 week with CBC, CMP.
Your medicines: (1) gabapentin 300mg three times daily [nerve pain medicine — may cause drowsiness]. (2) metoprolol 50mg once daily [heart rate and blood pressure medicine]. (3) sertraline 50mg once daily [antidepressant/anxiety medicine]. Do not suddenly stop this medicine — your doctor will gradually reduce the dose ...
Cardiology
Prescription
medium
1,708
45 y/o F with PMH of seizure disorder on Keppra, Parkinson's disease, HTN, OSA on CPAP, admitted for hypertensive urgency. BP 210/120. IV medications started to lower gradually. Managed per protocol with improvement. Diabetic diet, SMBG BID. D/C on prednisone taper, acetaminophen 650mg Q6H PRN, clopidogrel 75mg daily. ...
A 45-year-old woman with a history of seizure disorder [on Keppra], Parkinson's disease, high blood pressure, and sleep apnea [uses a breathing machine at night] was admitted for dangerously high blood pressure. BP 210/120. IV medications started to lower gradually. They were treated according to standard guidelines an...
Cardiology
Discharge Summary
high
1,709
CT Head without contrast: Chronic lacunar infarcts in bilateral basal ganglia. No acute intracranial hemorrhage. Paranasal sinuses clear. No midline shift. Subarachnoid hemorrhage in bilateral sylvian fissures.
CT scan of the head results: There are signs of small old strokes in the deep parts of the brain. There is no bleeding in the brain. The sinuses are clear with no infection. The brain is centered normally. There is bleeding around the brain surface, particularly in the grooves on both sides.
Neurology
Radiology Report
high
1,710
CXR PA: Right-sided pneumothorax. Sternotomy wires intact. Hyperinflated lungs consistent with COPD. Right middle lobe atelectasis. Clear lung fields bilaterally.
Chest X-ray results: The right lung has partially collapsed due to air leaking into the chest cavity [pneumothorax]. The wires from prior heart surgery are intact. The lungs appear over-inflated, which is typical of chronic lung disease [COPD/emphysema]. Part of the right lung has partially collapsed [atelectasis], pos...
Pulmonology
Radiology Report
high
1,711
CBC: WBC 5.1 (N), Hgb 17.9 (H), Plt 339 (N).
Your blood count results: White blood cells are 5.1 (normal). Hemoglobin is elevated at 17.9. Platelets are 339, which is normal.
Hematology
Lab Result
high
1,712
Delivery Note: G?P? at 39+1 weeks. Primary low-transverse C-section. Live male infant. APGAR 8/9. EBL within expected limits. Mother stable.
Birth summary: pregnancy reached about 39+1 weeks gestation. The baby was delivered by C-section through a low horizontal cut on the uterus. The newborn is a healthy male. APGAR scores were 8/9. Bleeding was normal. Mother did well after delivery.
Obstetrics
Delivery Note
high
1,713
Rx: Tab Xarelto 20mg daily with dinner. Tab clopidogrel 75mg daily. Adv: fall precautions, home safety evaluation Avoid NSAIDs. F/U 1 week with CBC, CMP.
Your medicines: (1) Xarelto 20mg once daily with dinner [blood thinner]. (2) Plavix (clopidogrel) 75mg once daily [blood thinner]. Advice: take steps to prevent falls — remove loose rugs, install grab bars, use night lights Do not take anti-inflammatory pain medicines like ibuprofen (Advil) or naproxen (Aleve) as they ...
Cardiology
Prescription
medium
1,714
25 y/o M with PMH of osteoporosis, CKD Stage 3, HTN, 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 azithromycin 500mg day 1 then 250mg x 4 days, carvedilol 12.5mg BID, entresto 49/51mg BID. F/U PCP in 2 weeks.
A 25-year-old man with a history of weak bones [osteoporosis], moderate kidney disease, and high blood pressure 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 guidelin...
Endocrinology
Discharge Summary
high
1,715
Levetiracetam 500mg BID; do not stop suddenly; report mood changes.
Anti-seizure medicine twice daily; taper only with clinician guidance; watch for mood side effects.
Neurology
Medication Instruction
low
1,716
46 y/o M with PMH of DM2, depression, CKD Stage 3, hypothyroidism, ICD in situ, admitted for PE. CTA positive for PE. Heparin started. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on atorvastatin 40mg QHS, Xarelto 20mg daily with dinner, ferrous sulfate 325mg BID. F/U P...
A 46-year-old man with a history of type 2 diabetes, depression, moderate kidney disease, underactive thyroid, and implanted heart defibrillator was admitted for a blood clot in the lungs [pulmonary embolism]. CT scan confirmed a blood clot in the lungs. Heparin started. They were treated according to standard guidelin...
Pulmonology
Discharge Summary
high
1,717
CBC: WBC 15.7 (H), Hgb 7.5 (L), Plt 318 (N).
Your blood count results: White blood cells are 15.7 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is low at 7.5, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 318, which is normal.
Hematology
Lab Result
high
1,718
69 y/o F with PMH of s/p THR, anxiety, depression, DVT/PE on warfarin, CHF, 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 amlodipine 5mg daily, clopidogrel 75mg daily. F...
A 69-year-old woman with a history of prior hip replacement, anxiety, depression, blood clots [on blood thinner warfarin], and heart failure 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 th...
Infectious Disease
Discharge Summary
high
1,719
34 y/o F with PMH of asthma, BPH, s/p TKR, Parkinson's disease, admitted for NSTEMI. Troponin elevated confirming heart muscle damage. Managed per protocol with improvement. Head injury precautions x 48hrs. D/C on atorvastatin 40mg QHS, Eliquis 5mg BID, ibuprofen 400mg Q6H PRN with food, Augmentin 875/125 BID x 7 days,...
A 34-year-old woman with a history of asthma, enlarged prostate, prior knee replacement, and Parkinson's disease 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 i...
Cardiology
Discharge Summary
high
1,720
84 y/o M with PMH of hypothyroidism, ICD in situ, HFpEF, HFrEF (EF 30%), admitted for hypertensive urgency. BP 210/120. IV medications started to lower gradually. Managed per protocol with improvement. Smoking cessation counseling provided. D/C on ondansetron 4mg Q8H PRN N/V, carvedilol 12.5mg BID, ferrous sulfate 325m...
A 84-year-old man with a history of underactive thyroid, implanted heart defibrillator, heart failure with stiff heart muscle, and heart failure with weak pumping (30%) was admitted for dangerously high blood pressure. BP 210/120. IV medications started to lower gradually. They were treated according to standard guidel...
Cardiology
Discharge Summary
high
1,721
US Abdomen: GB sludge, no stones. Simple renal cysts bilaterally. Ascites moderate amount. CBD 5mm, not dilated.
Abdominal ultrasound results: The gallbladder contains thickened bile [sludge] but no stones. Both kidneys have harmless fluid-filled cysts. There is a moderate amount of fluid in the belly [ascites]. The bile duct is normal size [not blocked].
Gastroenterology
Radiology Report
high
1,722
79 y/o M with PMH of gout, OA, HLD, CAD, admitted for cellulitis L lower extremity. Area was red, warm, and swollen. Marked with pen to track spread. Managed per protocol with improvement. Daily weights, 1.5L fluid restriction, low sodium diet. D/C on Xarelto 20mg daily with dinner, escitalopram 10mg daily, timolol 0.5...
A 79-year-old man with a history of gout, arthritis [osteoarthritis], high cholesterol, and coronary artery disease [heart artery blockages] 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 improve...
Infectious Disease
Discharge Summary
high
1,723
CXR PA: Pacemaker leads in appropriate position. Cardiomegaly with CTR >0.5. Moderate right pleural effusion. Port-a-cath in appropriate position. Left lower lobe consolidation.
Chest X-ray results: The pacemaker wires are in the correct position. The heart appears larger than normal. There is a moderate amount of fluid around the right lung. The implanted medication port is in the correct position. There is an area in the lower left lung that appears infected.
Pulmonology
Radiology Report
high
1,724
Delivery Note: G?P? at 39+1 weeks. SVD. Live female infant. APGAR 8/9. 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 8/9. Bleeding was normal. Mother did well after delivery.
Obstetrics
Delivery Note
high
1,725
MRI Lumbar Spine: No compression fracture. Conus medullaris at L1, normal. C5-C6 disc herniation with cord compression.
MRI of the lower back results: No bones are broken or collapsed. The spinal cord ends at a normal level. At C5-C6 in the neck, a disc has pushed out and is pressing on the spinal cord — this is significant.
Orthopedics
Radiology Report
high
1,726
Rx: Tab amoxicillin 500mg TID x 10 days. Tab gabapentin 300mg TID. Tab levothyroxine 75mcg daily on empty stomach. Tab warfarin 5mg daily. Adv: avoid alcohol, hepatotoxic drugs. F/U INR in 3 days.
Your medicines: (1) amoxicillin 500mg three times daily for 10 days [antibiotic — complete full course]. (2) gabapentin 300mg three times daily [nerve pain medicine — may cause drowsiness]. (3) levothyroxine 75mcg on empty stomach 30 min before breakfast [thyroid medicine]. (4) warfarin 5mg once daily [blood thinner — ...
Neurology
Prescription
high
1,727
Escitalopram 10mg AM; effect builds over weeks; avoid abrupt alcohol use.
Antidepressant taken in the morning; benefits increase over several weeks; limit alcohol.
Psychiatry
Medication Instruction
high
1,728
Escitalopram 10mg AM; effect builds over weeks; avoid abrupt alcohol use.
Antidepressant taken in the morning; benefits increase over several weeks; limit alcohol.
Psychiatry
Medication Instruction
high
1,729
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
1,730
76 y/o M with PMH of A-fib, HFrEF (EF 30%), OSA on CPAP, GERD, ICD in situ, admitted for cellulitis R lower extremity. Leg was red, swollen, and warm. IV antibiotics started. Managed per protocol with improvement. Daily weights, 1.5L fluid restriction, low sodium diet. D/C on Humalog per SSI, atorvastatin 40mg QHS, ato...
A 76-year-old man with a history of irregular heartbeat [atrial fibrillation], heart failure with weak pumping (30%), sleep apnea [uses a breathing machine at night], acid reflux, and implanted heart defibrillator was admitted for a skin infection in the right leg. Leg was red, swollen, and warm. IV antibiotics started...
Infectious Disease
Discharge Summary
high
1,731
CXR PA: Mild cardiomegaly. No pneumothorax. Small left pleural effusion.
Chest X-ray results: The heart is slightly larger than normal. There is no collapsed lung. There is a small amount of fluid around the left lung.
Pulmonology
Radiology Report
high
1,732
MRI Lumbar Spine: L5-S1 disc desiccation with mild bulge. Conus medullaris at L1, normal.
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 spinal cord ends at a normal level.
Orthopedics
Radiology Report
high
1,733
Latanoprost OU QHS; remove contacts before drops; punctal occlusion 1 min.
Glaucoma drops at bedtime in both eyes; remove contacts before use and gently press inner corners for one minute.
Ophthalmology
Medication Instruction
high
1,734
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
1,735
Thyroid panel: TSH 0.28 (L), Free T4 2.1.
Your thyroid test results: TSH is low at 0.28 (normal 0.4-4.5), meaning your thyroid is overactive [hyperthyroidism]. Free T4 is high — consistent with an overactive thyroid.
Endocrinology
Lab Result
high
1,736
Rx: Tab acetaminophen 650mg Q6H PRN. Tab clopidogrel 75mg daily. Tab hydroxychloroquine 200mg BID. Tab ferrous sulfate 325mg BID. Tab entresto 49/51mg BID. Adv: SMBG BID, diabetic diet Avoid grapefruit juice. F/U 1 week with wound check.
Your medicines: (1) Tylenol (acetaminophen) 650mg every 6 hours as needed [do not exceed 3000mg/day]. (2) Plavix (clopidogrel) 75mg once daily [blood thinner]. (3) hydroxychloroquine 200mg twice daily [immune-modulating medicine — eye exams needed]. (4) iron supplement 325mg twice daily [for low blood count — take with...
Cardiology
Prescription
high
1,737
CXR PA: Osseous structures intact. Hyperinflated lungs consistent with COPD. ET tube 3cm above carina. No pneumothorax. Cardiomegaly with CTR >0.5.
Chest X-ray results: The bones look normal with no fractures. The lungs appear over-inflated, which is typical of chronic lung disease [COPD/emphysema]. The breathing tube is in good position. There is no collapsed lung. The heart appears larger than normal.
Pulmonology
Radiology Report
high
1,738
Rx: Tab escitalopram 10mg daily. Tab tramadol 50mg Q6H PRN pain. Tab atorvastatin 40mg QHS. Tab timolol 0.5% OU BID. Tab Augmentin 875/125 BID x 7 days. Avoid grapefruit juice Adv: SMBG BID, diabetic diet. F/U 2 weeks with INR.
Your medicines: (1) escitalopram 10mg once daily [antidepressant/anxiety medicine]. (2) tramadol 50mg every 6 hours as needed for pain [may cause drowsiness — max 4/day]. (3) atorvastatin 40mg at bedtime [cholesterol medicine]. (4) timolol eye drops in both eyes twice daily [lowers eye pressure for glaucoma]. (5) Augme...
Cardiology
Prescription
high
1,739
76 y/o M with PMH of hypothyroidism, HLD, s/p THR, 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 Augmentin 875/125 BID x 7 days, albuterol MDI 2 puffs Q4-6H PRN, metformin 500mg BI...
A 76-year-old man with a history of underactive thyroid, high cholesterol, and prior hip replacement 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 gauze with ...
Gastroenterology
Discharge Summary
high
1,740
MRI Lumbar Spine: Central canal stenosis at L3-L4. Facet joint hypertrophy at L4-L5. 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. The small joints in the spine at L4-L5 are enlarged from arthritis. At the L5-S1 level, the disc is dried out [worn] with a slight bulge, but not causing significant pressure.
Orthopedics
Radiology Report
high
1,741
Rx: Tab glipizide 5mg BID AC. Tab Augmentin 875/125 BID x 7 days. Tab carvedilol 12.5mg BID. Tab hydroxychloroquine 200mg BID. Tab entresto 49/51mg BID. Adv: DASH diet, daily BP monitoring Adv: wound care with daily dressing changes. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT.
Your medicines: (1) glipizide 5mg twice daily before meals [helps release insulin]. (2) Augmentin 875mg twice daily for 7 days [antibiotic]. (3) carvedilol 12.5mg twice daily [heart medicine]. (4) hydroxychloroquine 200mg twice daily [immune-modulating medicine — eye exams needed]. (5) Entresto 49/51mg twice daily [hea...
Cardiology
Prescription
high
1,742
CT Head without contrast: Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. Subarachnoid hemorrhage in bilateral sylvian fissures. No acute intracranial hemorrhage.
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 is no bleeding in the brain.
Neurology
Radiology Report
high
1,743
Rx: Tab ASA 81mg daily. Tab lisinopril 10mg daily. Tab potassium chloride 20mEq daily. Tab ibuprofen 400mg Q6H PRN with food. Tab furosemide 40mg BID. Adv: low potassium diet Do not stop abruptly, taper as directed. F/U 1 month with repeat imaging.
Your medicines: (1) baby aspirin 81mg once daily [prevents blood clots]. (2) lisinopril 10mg once daily [blood pressure medicine that also protects kidneys]. (3) potassium supplement 20mEq once daily [replaces potassium lost from water pills]. (4) ibuprofen 400mg every 6 hours as needed with food [anti-inflammatory pai...
Cardiology
Prescription
high
1,744
59 y/o M with PMH of CKD Stage 4, A-fib, DVT/PE on warfarin, admitted for cholecystitis. US showed gallbladder wall thickening and stones. Surgery consulted. Managed per protocol with improvement. Compression stockings when ambulating. D/C on gabapentin 300mg TID, sertraline 50mg daily, Dulcolax 10mg QHS PRN, Eliquis 5...
A 59-year-old man with a history of advanced kidney disease, irregular heartbeat [atrial fibrillation], and blood clots [on blood thinner warfarin] was admitted for gallbladder infection/inflammation. US showed gallbladder wall thickening and stones. Surgery consulted. They were treated according to standard guidelines...
General Surgery
Discharge Summary
high
1,745
Levetiracetam 500mg BID; do not stop suddenly; report mood changes.
Anti-seizure medicine twice daily; taper only with clinician guidance; watch for mood side effects.
Neurology
Medication Instruction
high
1,746
Doxycycline 100mg BID x 14 days with water; stay upright 30 min; avoid sun.
Take this antibiotic twice daily for 14 days with plenty of water, stay upright after doses, and use sun protection.
Infectious Disease
Medication Instruction
low
1,747
Rx: Tab furosemide 40mg daily. Tab atorvastatin 40mg QHS. Avoid grapefruit juice Adv: DASH diet, daily BP monitoring. F/U 6 weeks with LFTs.
Your medicines: (1) furosemide (Lasix) 40mg once daily [water pill to remove extra fluid]. (2) atorvastatin 40mg at bedtime [cholesterol medicine]. Do not drink grapefruit juice as it interferes with this medication Advice: follow the DASH diet (rich in fruits, vegetables, lean protein, low in salt) and check blood pre...
Cardiology
Prescription
medium
1,748
HbA1c: 11.2% (H). FBS: 143 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 143, which is high (normal is 70-100). Urgent medication adjustment needed. Very high risk of diabetes complications at this level.
Endocrinology
Lab Result
high
1,749
Rx: Tab metoprolol succinate 50mg daily. Tab metoprolol 25mg BID. Tab Dulcolax 10mg QHS PRN. albuterol MDI 2 puffs Q4-6H PRN. Tab Augmentin 875/125 BID x 7 days. Adv: low salt low sugar diet, regular exercise. F/U PCP in 1 week for BP recheck.
Your medicines: (1) metoprolol 50mg once daily [heart rate and blood pressure medicine]. (2) metoprolol 25mg twice daily [slows heart rate and lowers blood pressure]. (3) Dulcolax 10mg at bedtime as needed [for constipation]. (4) albuterol inhaler 2 puffs every 4-6 hours as needed [rescue inhaler for breathing]. (5) Au...
Cardiology
Prescription
high
1,750
Rx: Tab Xarelto 20mg daily with dinner. Lantus 20U QHS. Adv: weight bearing exercise, calcium/vit D supplementation Adv: fall precautions, home safety evaluation. F/U 2 weeks.
Your medicines: (1) Xarelto 20mg once daily with dinner [blood thinner]. (2) Lantus insulin 20 units at bedtime [long-acting insulin]. Advice: do weight-bearing exercises (walking, light weights) and take calcium and vitamin D for bone strength Advice: take steps to prevent falls — remove loose rugs, install grab bars,...
Endocrinology
Prescription
medium
1,751
76 y/o M with PMH of BPH, OSA on CPAP, gout, CHF, DM1, admitted for PE. CTA positive for PE. Heparin started. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on pregabalin 75mg BID, ibuprofen 400mg Q6H PRN with food, Humalog per SSI, tramadol 50mg Q6H PRN pain. F/U surgery in 2 we...
A 76-year-old man with a history of enlarged prostate, sleep apnea [uses a breathing machine at night], gout, heart failure, and type 1 diabetes was admitted for a blood clot in the lungs [pulmonary embolism]. CT scan confirmed a blood clot in the lungs. Heparin started. They were treated according to standard guidelin...
Pulmonology
Discharge Summary
high
1,752
43 y/o F with PMH of CAD, OA, s/p THR, 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 amlodipine 5mg daily, losartan 50mg daily, metformin 1000mg BID, ferrous sulfate 325mg BID. F/U...
A 43-year-old woman with a history of coronary artery disease [heart artery blockages], arthritis [osteoarthritis], and prior hip replacement 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 ...
Gastroenterology
Discharge Summary
high
1,753
Rx: Tab lisinopril 10mg daily. Tab methotrexate 15mg weekly. Tab metoprolol 25mg BID. Tab azithromycin 500mg day 1 then 250mg x 4 days. Tab Xarelto 20mg daily with dinner. Avoid NSAIDs Adv: weight bearing exercise, calcium/vit D supplementation. F/U 1 week with wound check.
Your medicines: (1) lisinopril 10mg once daily [blood pressure medicine that also protects kidneys]. (2) methotrexate 15mg once weekly [immune-suppressing medicine for arthritis — requires monitoring]. (3) metoprolol 25mg twice daily [slows heart rate and lowers blood pressure]. (4) azithromycin: 500mg on day 1, then 2...
Cardiology
Prescription
high
1,754
Rx: Tab furosemide 40mg BID. Tab Dulcolax 10mg QHS PRN. Avoid grapefruit juice. F/U 6 weeks with LFTs.
Your medicines: (1) furosemide (Lasix) 40mg twice daily [water pill]. (2) Dulcolax 10mg at bedtime as needed [for constipation]. Do not drink grapefruit juice as it interferes with this medication. Come back in 6 weeks for liver function blood tests.
Cardiology
Prescription
medium
1,755
MRI Lumbar Spine: L5-S1 disc desiccation with mild bulge. No compression fracture.
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. No bones are broken or collapsed.
Orthopedics
Radiology Report
high
1,756
70 y/o M with PMH of Parkinson's disease, PPM in situ, asthma, DM1, admitted for small bowel obstruction. CT showed dilated loops of bowel with transition point. Managed per protocol with improvement. Smoking cessation counseling provided. D/C on albuterol MDI 2 puffs Q4-6H PRN, atorvastatin 40mg QHS, ASA 81mg daily, a...
A 70-year-old man with a history of Parkinson's disease, implanted pacemaker, asthma, and type 1 diabetes was admitted for a blockage in the small intestine. CT scan showed dilated loops of bowel with transition point. They were treated according to standard guidelines and improved. Strongly encouraged to quit smoking....
General Surgery
Discharge Summary
high
1,757
70 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 70-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
1,758
Procedure: PCI with DES to LAD. Pt 31 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 heart catheter procedure to place a stent in a heart artery for a 31-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.
Cardiology
Procedure Note
high
1,759
36 y/o M with PMH of DM1, PPM in situ, admitted for appendicitis. CT confirmed. Taken to OR for laparoscopic appendectomy. Managed per protocol with improvement. Smoking cessation counseling provided. D/C on escitalopram 10mg daily, metformin 500mg BID, metoprolol 25mg BID. F/U hematology in 2 weeks.
A 36-year-old man with a history of type 1 diabetes, and implanted pacemaker was admitted for inflammation of the appendix. CT confirmed. Taken to OR for laparoscopic appendectomy. They were treated according to standard guidelines and improved. Strongly encouraged to quit smoking. Resources and support provided.. Medi...
General Surgery
Discharge Summary
high
1,760
70 y/o M with PMH of h/o TIA, PPM in situ, s/p CABG, CHF, admitted for sepsis secondary to UTI. Blood cultures positive. Lactate elevated. Managed per protocol with improvement. Daily weights, 1.5L fluid restriction, low sodium diet. D/C on escitalopram 10mg daily, pregabalin 75mg BID, Spiriva 18mcg daily. F/U cardiolo...
A 70-year-old man with a history of history of mini-stroke, implanted pacemaker, prior heart bypass surgery, and heart failure 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 stand...
Infectious Disease
Discharge Summary
high
1,761
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
1,762
Thyroid panel: TSH 7.52 (H), Free T4 0.6.
Your thyroid test results: TSH is elevated at 7.52 (normal 0.4-4.5), meaning your thyroid is underactive [hypothyroidism]. Free T4 is low — confirming the thyroid is not producing enough hormone.
Endocrinology
Lab Result
high
1,763
Rx: Tab ferrous sulfate 325mg BID. Tab ciprofloxacin 500mg BID x 5 days. Tab sertraline 50mg daily. Tab furosemide 40mg BID. Tab amlodipine 5mg daily. Do not stop abruptly, taper as directed. F/U 4 weeks with TSH, Free T4.
Your medicines: (1) iron supplement 325mg twice daily [for low blood count — take with vitamin C]. (2) ciprofloxacin 500mg twice daily for 5 days [antibiotic — avoid dairy within 2 hours]. (3) sertraline 50mg once daily [antidepressant/anxiety medicine]. (4) furosemide (Lasix) 40mg twice daily [water pill]. (5) amlodip...
Cardiology
Prescription
high
1,764
Procedure: Laparoscopic appendectomy. Pt 67 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 67-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
1,765
CBC: WBC 2.5 (L), Hgb 7.6 (L), Plt 229 (N).
Your blood count results: White blood cells are 2.5 (low, meaning your immune system may be weakened). Hemoglobin is low at 7.6, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 229, which is normal.
Hematology
Lab Result
high
1,766
87 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 87-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
1,767
32 y/o M with PMH of osteoporosis, HFrEF (EF 30%), CKD Stage 4, gout, admitted for acute CHF exacerbation. BNP elevated. CXR showed pulmonary edema. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on latanoprost 0.005% OU QHS, gabapentin 300mg TID, Eliquis 5mg BID. F/U car...
A 32-year-old man with a history of weak bones [osteoporosis], heart failure with weak pumping (30%), advanced kidney disease, and gout was admitted for worsening heart failure with fluid buildup. BNP elevated. Chest X-ray showed pulmonary edema. They were treated according to standard guidelines and improved. Use the ...
Cardiology
Discharge Summary
high
1,768
CT Head without contrast: Subarachnoid hemorrhage in bilateral sylvian fissures. No midline shift. Chronic lacunar infarcts in bilateral basal ganglia.
CT scan of the head results: There is bleeding around the brain surface, particularly in the grooves on both sides. The brain is centered normally. There are signs of small old strokes in the deep parts of the brain.
Neurology
Radiology Report
high
1,769
Procedure: Colonoscopy with polypectomy. Pt 51 y/o F. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed.
This note describes colon exam with removal of polyps for a 51-year-old woman. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders.
Gastroenterology
Procedure Note
high
1,770
47 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 47-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
1,771
Levetiracetam 500mg BID; do not stop suddenly; report mood changes.
Anti-seizure medicine twice daily; taper only with clinician guidance; watch for mood side effects.
Neurology
Medication Instruction
medium
1,772
US Abdomen: Pancreas unremarkable. Liver 18cm, diffusely echogenic consistent with hepatic steatosis. CBD 12mm, dilated. CBD 5mm, not dilated. Moderate right hydronephrosis. Spleen 11cm, normal.
Abdominal ultrasound results: The pancreas looks normal. The liver is slightly enlarged and appears brighter than normal, indicating fatty liver disease. The bile duct is wider than normal [dilated], which may indicate a blockage. The bile duct is normal size [not blocked]. The right kidney is swollen because urine is ...
Gastroenterology
Radiology Report
high
1,773
73 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 73-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
1,774
Rx: Tab pantoprazole 40mg AC breakfast. Tab ferrous sulfate 325mg BID. Tab warfarin 5mg daily. Tab atorvastatin 80mg QHS. Tab Eliquis 5mg BID. Adv: DASH diet, daily BP monitoring Adv: high fiber diet, adequate hydration. F/U 2 weeks.
Your medicines: (1) pantoprazole 40mg before breakfast [acid-reducing medicine]. (2) iron supplement 325mg twice daily [for low blood count — take with vitamin C]. (3) warfarin 5mg once daily [blood thinner — requires regular INR blood tests]. (4) atorvastatin 80mg at bedtime [high-dose cholesterol medicine]. (5) Eliqu...
Hematology
Prescription
high
1,775
37 y/o F with PMH of CAD, PPM in situ, BPH, ICD in situ, h/o CVA, admitted for syncope. Cardiac workup and neurologic evaluation performed. Managed per protocol with improvement. Elevate R leg above heart level when resting. D/C on furosemide 40mg daily, azithromycin 500mg day 1 then 250mg x 4 days, ibuprofen 400mg Q6H...
A 37-year-old woman with a history of coronary artery disease [heart artery blockages], implanted pacemaker, enlarged prostate, implanted heart defibrillator, and history of stroke was admitted for fainting [loss of consciousness]. Cardiac workup and neurologic evaluation performed. They were treated according to stand...
Cardiology
Discharge Summary
high
1,776
Procedure: R TKA. Pt 46 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 total knee replacement on the right for a 46-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
1,777
90 y/o M with PMH of hypothyroidism, h/o CVA, OA, admitted for small bowel obstruction. CT showed dilated loops of bowel with transition point. Managed per protocol with improvement. Diabetic diet, SMBG BID. D/C on amlodipine 10mg daily, glipizide 5mg BID AC, spironolactone 25mg daily, Humalog per SSI. F/U oncology in ...
A 90-year-old man with a history of underactive thyroid, history of stroke, and arthritis [osteoarthritis] was admitted for a blockage in the small intestine. CT scan showed dilated loops of bowel with transition point. They were treated according to standard guidelines and improved. Follow a diabetes-friendly diet (li...
General Surgery
Discharge Summary
high
1,778
31 y/o F 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 31-year-old woman 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. Dia...
Emergency Medicine
Clinical Note
high
1,779
Delivery Note: G?P? at 37+3 weeks. SVD. Live male infant. APGAR 7/9. EBL within expected limits. Mother stable.
Birth summary: pregnancy reached about 37+3 weeks gestation. The baby was delivered by normal vaginal delivery. The newborn is a healthy male. APGAR scores were 7/9. Bleeding was normal. Mother did well after delivery.
Obstetrics
Delivery Note
high
1,780
Rx: Tab amoxicillin 500mg TID x 10 days. Tab methotrexate 15mg weekly. Tab Xarelto 20mg daily with dinner. Tab potassium chloride 20mEq daily. Adv: weight bearing exercise, calcium/vit D supplementation. F/U INR in 3 days.
Your medicines: (1) amoxicillin 500mg three times daily for 10 days [antibiotic — complete full course]. (2) methotrexate 15mg once weekly [immune-suppressing medicine for arthritis — requires monitoring]. (3) Xarelto 20mg once daily with dinner [blood thinner]. (4) potassium supplement 20mEq once daily [replaces potas...
Infectious Disease
Prescription
high
1,781
CXR PA: Right lower lobe consolidation. NG tube tip in stomach. Compression fracture T12.
Chest X-ray results: There is an area in the lower right lung that appears infected, suggesting pneumonia. The feeding/drainage tube tip is correctly positioned in the stomach. There is a compression fracture [collapsed bone] in the lower spine at T12.
Pulmonology
Radiology Report
high
1,782
Delivery Note: G?P? at 39+1 weeks. SVD. Live female infant. APGAR 8/9. 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 8/9. Bleeding was normal. Mother did well after delivery.
Obstetrics
Delivery Note
high
1,783
59 y/o M with PMH of DVT/PE on warfarin, s/p THR, admitted for chest pain r/o ACS. Serial troponins and cardiac monitoring performed. Managed per protocol with improvement. Compression stockings when ambulating. D/C on warfarin 5mg daily, spironolactone 25mg daily. F/U wound care in 3 days.
A 59-year-old man with a history of blood clots [on blood thinner warfarin], and prior hip replacement was admitted for chest pain being evaluated for a possible heart attack. Serial troponins and cardiac monitoring performed. They were treated according to standard guidelines and improved. Wear compression stockings o...
Cardiology
Discharge Summary
high
1,784
Rx: Tab metoprolol 25mg BID. Tab entresto 49/51mg BID. Tab losartan 50mg daily. Tab lisinopril 20mg daily. Tab atorvastatin 80mg QHS. Adv: fall precautions, home safety evaluation Adv: elevate affected limb, compression stockings. F/U 2 weeks.
Your medicines: (1) metoprolol 25mg twice daily [slows heart rate and lowers blood pressure]. (2) Entresto 49/51mg twice daily [heart failure medicine]. (3) losartan 50mg once daily [blood pressure medicine]. (4) lisinopril 20mg once daily [blood pressure medicine]. (5) atorvastatin 80mg at bedtime [high-dose cholester...
Cardiology
Prescription
high
1,785
CXR PA: Bilateral pleural effusions. Left lower lobe consolidation. Pacemaker leads in appropriate position. Bilateral hilar lymphadenopathy.
Chest X-ray results: There is fluid collecting around both lungs. There is an area in the lower left lung that appears infected. The pacemaker wires are in the correct position. There are enlarged lymph nodes at the root of both lungs, which needs further evaluation.
Pulmonology
Radiology Report
high
1,786
44 y/o M with PMH of osteoporosis, SLE, asthma, ICD in situ, admitted for STEMI. ECG showed ST elevation. Troponin markedly elevated. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on albuterol MDI 2 puffs Q4-6H PRN, Xarelto 20mg daily with dinner, potassium chloride 20mEq daily, atorvastat...
A 44-year-old man with a history of weak bones [osteoporosis], lupus, asthma, and implanted heart defibrillator 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 preve...
Cardiology
Discharge Summary
high
1,787
31 y/o F 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 31-year-old woman 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. Dia...
Emergency Medicine
Clinical Note
high
1,788
64 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 64-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
1,789
MRI Lumbar Spine: No compression fracture. Central canal stenosis at L3-L4. L5-S1 disc desiccation with mild bulge.
MRI of the lower back results: No bones are broken or collapsed. 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
1,790
45 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 45-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
1,791
Lipid panel: TC 306, LDL 200, HDL 28, TG 476.
Your cholesterol results: Total cholesterol is 306. LDL (bad cholesterol) is very high at 200 (goal under 100), significantly increasing heart disease risk. HDL (good cholesterol) is too low at 28 (should be above 40 for men, 50 for women) — this is a risk factor for heart disease. Triglycerides are very high at 476 (n...
Cardiology
Lab Result
high
1,792
US Abdomen: Spleen 11cm, normal. CBD 5mm, not dilated. GB wall thickening with stones, positive Murphy's sign.
Abdominal ultrasound results: The spleen is a normal size. The bile duct is normal size [not blocked]. The gallbladder wall is thickened and gallstones are present — pressing on the gallbladder area caused pain [positive Murphy's sign], suggesting infection.
Gastroenterology
Radiology Report
high
1,793
CBC: WBC 19.7 (H), Hgb 6.2 (L), Plt 387 (N).
Your blood count results: White blood cells are 19.7 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is low at 6.2, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 387, which is normal.
Hematology
Lab Result
high
1,794
Rx: Tab atorvastatin 40mg QHS. Tab montelukast 10mg QHS. Adv: weight bearing exercise, calcium/vit D supplementation Adv: DASH diet, daily BP monitoring. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT.
Your medicines: (1) atorvastatin 40mg at bedtime [cholesterol medicine]. (2) montelukast 10mg at bedtime [asthma/allergy medicine]. Advice: do weight-bearing exercises (walking, light weights) and take calcium and vitamin D for bone strength Advice: follow the DASH diet (rich in fruits, vegetables, lean protein, low in...
Cardiology
Prescription
medium
1,795
25 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 25-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
1,796
Lipid panel: TC 308, LDL 175, HDL 79, TG 471.
Your cholesterol results: Total cholesterol is 308. LDL (bad cholesterol) is very high at 175 (goal under 100), significantly increasing heart disease risk. HDL (good cholesterol) is good at 79. Triglycerides are very high at 471 (normal under 150) — increases risk of pancreatitis.
Cardiology
Lab Result
high
1,797
33 y/o M with PMH of SLE, OSA on CPAP, admitted for sepsis secondary to UTI. Blood cultures positive. Lactate elevated. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on ciprofloxacin 500mg BID x 5 days, acetaminophen 650mg Q6H PRN, potassium chloride 20mEq daily, Augmentin 875/125 BID x 7 ...
A 33-year-old man with a history of lupus, and sleep apnea [uses a breathing machine at night] 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 standard guidelines and improved. Be ...
Infectious Disease
Discharge Summary
high
1,798
85 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 85-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
1,799
MRI Lumbar Spine: No compression fracture. L5-S1 disc desiccation with mild bulge.
MRI of the lower back results: No bones are broken or collapsed. At the L5-S1 level, the disc is dried out [worn] with a slight bulge, but not causing significant pressure.
Orthopedics
Radiology Report
high
1,800
47 y/o M with PMH of PAD, hypothyroidism, admitted for acute stroke (CVA). CT showed acute ischemic infarct. tPA administered. Managed per protocol with improvement. Compression stockings when ambulating. D/C on potassium chloride 20mEq daily, losartan 50mg daily, latanoprost 0.005% OU QHS, hydroxychloroquine 200mg BID...
A 47-year-old man with a history of poor blood flow in the legs [peripheral artery disease], and underactive thyroid was admitted for a stroke [blocked blood vessel in the brain]. CT scan showed acute ischemic infarct. clot-dissolving medicine was given. They were treated according to standard guidelines and improved. ...
Neurology
Discharge Summary
high