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401 | CBC: WBC 15.1 (H), Hgb 9.4 (L), Plt 221 (N). | Your blood count results: White blood cells are 15.1 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is low at 9.4, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 221, which is normal. | Hematology | Lab Result | high |
402 | 47 y/o M with PMH of HLD, h/o CVA, BPH, s/p TKR, admitted for fall with hip fracture. X-ray confirmed femoral neck fracture. Orthopedics consulted. Managed per protocol with improvement. Wound care: daily dressing changes with wet-to-dry gauze. D/C on ferrous sulfate 325mg BID, montelukast 10mg QHS. F/U surgery in 10 d... | A 47-year-old man with a history of high cholesterol, history of stroke, enlarged prostate, and prior knee replacement 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. Change the wound dressing daily:... | Orthopedics | Discharge Summary | high |
403 | Rx: Tab lisinopril 20mg daily. Tab hydroxychloroquine 200mg BID. Tab Dulcolax 10mg QHS PRN. Adv: DASH diet, daily BP monitoring Adv: avoid alcohol, hepatotoxic drugs. F/U 2 weeks with INR. | Your medicines: (1) lisinopril 20mg once daily [blood pressure medicine]. (2) hydroxychloroquine 200mg twice daily [immune-modulating medicine — eye exams needed]. (3) Dulcolax 10mg at bedtime as needed [for constipation]. Advice: follow the DASH diet (rich in fruits, vegetables, lean protein, low in salt) and check bl... | Cardiology | Prescription | medium |
404 | CT Head without contrast: No acute intracranial hemorrhage. Mild generalized cerebral atrophy appropriate for age. No mass effect. Subarachnoid hemorrhage in bilateral sylvian fissures. No midline shift. | 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 are no tumors or masses pushing on the brain. There is bleeding around the brain surface, particularly in the grooves on both sides. The brain is centered normally. | Neurology | Radiology Report | high |
405 | Rx: Tab azithromycin 500mg day 1 then 250mg x 4 days. Tab metoprolol 25mg BID. Adv: SMBG BID, diabetic diet. F/U PCP in 1 week for BP recheck. | Your medicines: (1) azithromycin: 500mg on day 1, then 250mg for the next 4 days [antibiotic]. (2) metoprolol 25mg twice daily [slows heart rate and lowers blood pressure]. Advice: check your blood sugar twice daily and follow a diabetes-friendly diet. See your primary care doctor in 1 week to recheck blood pressure. | Cardiology | Prescription | medium |
406 | CBC: WBC 24.0 (H), Hgb 15.8 (N), Plt 263 (N). | Your blood count results: White blood cells are 24.0 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is normal at 15.8. Platelets are 263, which is normal. | Hematology | Lab Result | high |
407 | 25 y/o F with PMH of anxiety, A-fib, h/o CVA, seizure disorder on Keppra, 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 latanoprost 0.005% OU QHS, warfarin 5mg daily. F/U nephrology in 1 week. | A 25-year-old woman with a history of anxiety, irregular heartbeat [atrial fibrillation], history of stroke, and seizure disorder [on Keppra] was admitted for irregular heartbeat with dangerously fast rate. HR 150s. Diltiazem drip started for rate control. They were treated according to standard guidelines and improved... | Cardiology | Discharge Summary | high |
408 | 24 y/o F presenting to ED with fall from standing, R hip pain, unable to bear weight. Vitals: BP 142/78, HR 88, RR 16, O2 97%. X-ray pelvis: displaced R femoral neck fracture. Pre-op labs WNL. ECG: NSR. Dx: R femoral neck fracture. Pain management with IV morphine. NPO for OR. Ortho consult for hemiarthroplasty vs ORIF... | A 24-year-old woman came to the emergency room with fell from standing, severe right hip pain, unable to put weight on the right leg. Vital signs: blood pressure slightly high (pain), heart rate normal, breathing normal, oxygen normal. X-ray showed a broken hip bone (displaced femoral neck fracture) on the right side. ... | Emergency Medicine | Clinical Note | high |
409 | Rx: Tab Xarelto 20mg daily with dinner. Tab metformin 500mg BID. Tab amlodipine 10mg daily. Adv: elevate affected limb, compression stockings. F/U PCP in 1 week for BP recheck. | Your medicines: (1) Xarelto 20mg once daily with dinner [blood thinner]. (2) metformin 500mg twice daily with meals [blood sugar medicine]. (3) amlodipine 10mg once daily [blood pressure medicine]. Advice: keep the affected leg elevated when resting and wear compression stockings. See your primary care doctor in 1 week... | Cardiology | Prescription | medium |
410 | BMP: Na 140 (N), K 3.0 (L), BUN 65, Cr 1.7 (H), Glucose 389. | Your blood chemistry results: Sodium is normal at 140. Potassium is low at 3.0 — may cause muscle weakness and heart rhythm issues. Creatinine is elevated at 1.7 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 389 (high). | Nephrology | Lab Result | high |
411 | 38 y/o M with PMH of depression, asthma, admitted for chest pain r/o ACS. Serial troponins and cardiac monitoring performed. Managed per protocol with improvement. Smoking cessation counseling provided. D/C on ferrous sulfate 325mg BID, tramadol 50mg Q6H PRN pain, furosemide 40mg BID, omeprazole 20mg AC breakfast. F/U ... | A 38-year-old man with a history of depression, and asthma 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. Strongly encouraged to quit smoking. Resources and support provided.. Me... | Cardiology | Discharge Summary | high |
412 | HbA1c: 5.4% (N). FBS: 206 mg/dL (H). | Your diabetes blood test results: HbA1c is 5.4%, which is normal — you do not have diabetes. Fasting blood sugar was 206, which is high (normal is 70-100). No diabetes treatment needed. Continue healthy lifestyle. | Endocrinology | Lab Result | high |
413 | Rx: Tab pregabalin 75mg BID. Tab ASA 81mg daily. Adv: high fiber diet, adequate hydration Adv: weight bearing exercise, calcium/vit D supplementation. F/U 2 weeks. | Your medicines: (1) pregabalin 75mg twice daily [nerve pain medicine]. (2) baby aspirin 81mg once daily [prevents blood clots]. Advice: eat plenty of fiber (fruits, vegetables, whole grains) and drink enough water Advice: do weight-bearing exercises (walking, light weights) and take calcium and vitamin D for bone stren... | Cardiology | Prescription | medium |
414 | LFTs: AST 448 (H), ALT 531 (H), ALP 82, T.Bili 2.3 (H), Albumin 2.4. | Your liver blood test results: Liver enzymes (AST 448, ALT 531) are severely elevated, indicating significant liver damage (normal is under 40). Bilirubin is high at 2.3 (normal under 1.2) — may cause yellowing of skin and eyes [jaundice]. Albumin is low at 2.4 (normal 3.5-5.5), suggesting the liver is struggling to ma... | Gastroenterology | Lab Result | high |
415 | 80 y/o M with PMH of PAD, CKD Stage 3, obesity (BMI 38), OSA on CPAP, BPH, admitted for cellulitis R lower extremity. Leg was red, swollen, and warm. IV antibiotics started. Managed per protocol with improvement. Strict NPO after midnight before procedure. D/C on ferrous sulfate 325mg BID, azithromycin 500mg day 1 then... | A 80-year-old man with a history of poor blood flow in the legs [peripheral artery disease], moderate kidney disease, obesity, sleep apnea [uses a breathing machine at night], and enlarged prostate was admitted for a skin infection in the right leg. Leg was red, swollen, and warm. IV antibiotics started. They were trea... | Infectious Disease | Discharge Summary | high |
416 | 32 y/o M presenting to ED with substernal CP radiating to L arm x 1hr, diaphoresis. Vitals: BP 165/95, HR 92, RR 18, O2 98%. ECG: ST elevation V1-V4. Troponin 2.1 (H). Dx: STEMI. Cath lab activated. ASA 325mg, Plavix 600mg, heparin bolus. Emergent PCI. | A 32-year-old man came to the emergency room with crushing chest pain spreading to the left arm for 1 hour with heavy sweating. Vital signs: blood pressure elevated, heart rate slightly fast, breathing normal, oxygen normal. Heart test (ECG) showed a heart attack pattern. Blood test confirmed heart muscle damage. Diagn... | Emergency Medicine | Clinical Note | high |
417 | 82 y/o M with PMH of HLD, seizure disorder on Keppra, s/p CABG, HTN, admitted for TIA. Symptoms resolved. MRI negative for infarct. Managed per protocol with improvement. Elevate R leg above heart level when resting. D/C on escitalopram 10mg daily, levothyroxine 75mcg daily on empty stomach, prednisone taper, calcium +... | A 82-year-old man with a history of high cholesterol, seizure disorder [on Keppra], prior heart bypass surgery, and high blood pressure was admitted for a mini-stroke [temporary loss of brain function]. Symptoms resolved. MRI negative for infarct. They were treated according to standard guidelines and improved. When re... | Neurology | Discharge Summary | high |
418 | 54 y/o M with PMH of A-fib, DM2, admitted for STEMI. ECG showed ST elevation. Troponin markedly elevated. Managed per protocol with improvement. Strict I&O, daily weights. D/C on pantoprazole 40mg AC breakfast, gabapentin 300mg TID. F/U hematology in 2 weeks. | A 54-year-old man with a history of irregular heartbeat [atrial fibrillation], and type 2 diabetes 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. Track how much you drink and uri... | Cardiology | Discharge Summary | high |
419 | Rx: Tab amoxicillin 500mg TID x 10 days. Tab entresto 49/51mg BID. Tab lisinopril 10mg daily. Spiriva 18mcg daily. Tab ferrous sulfate 325mg BID. Adv: low salt diet, fluid restriction 1.5L/day. F/U INR in 3 days. | Your medicines: (1) amoxicillin 500mg three times daily for 10 days [antibiotic — complete full course]. (2) Entresto 49/51mg twice daily [heart failure medicine]. (3) lisinopril 10mg once daily [blood pressure medicine that also protects kidneys]. (4) Spiriva inhaler once daily [long-acting lung medicine]. (5) iron su... | Cardiology | Prescription | high |
420 | 82 y/o M with PMH of SLE, OSA on CPAP, CKD Stage 3, BPH, admitted for alcohol withdrawal. CIWA protocol initiated. Lorazepam given as needed. Managed per protocol with improvement. Compression stockings when ambulating. D/C on gabapentin 300mg TID, ASA 81mg daily, amlodipine 5mg daily, ibuprofen 400mg Q6H PRN with food... | A 82-year-old man with a history of lupus, sleep apnea [uses a breathing machine at night], moderate kidney disease, and enlarged prostate was admitted for withdrawal symptoms after stopping alcohol. CIWA protocol initiated. Lorazepam given as needed. They were treated according to standard guidelines and improved. Wea... | Psychiatry | Discharge Summary | high |
421 | 65 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 65-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 |
422 | 23 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 23-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 |
423 | CXR PA: Right middle lobe atelectasis. No pneumothorax. NG tube tip in stomach. Mild cardiomegaly. | Chest X-ray results: Part of the right lung has partially collapsed [atelectasis], possibly from mucus plugging. There is no collapsed lung. The feeding/drainage tube tip is correctly positioned in the stomach. The heart is slightly larger than normal. | Pulmonology | Radiology Report | high |
424 | Procedure: TURP for BPH. Pt 62 y/o F. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes scope surgery to trim enlarged prostate tissue for a 62-year-old woman. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | Urology | Procedure Note | high |
425 | US Abdomen: Spleen 11cm, normal. Spleen 16cm, splenomegaly. Moderate right hydronephrosis. Right kidney 10.5cm, no hydronephrosis. | Abdominal ultrasound results: The spleen is a normal size. The spleen is enlarged [splenomegaly]. The right kidney is swollen because urine is backing up [hydronephrosis], possibly from a blockage. Right kidney is normal size with no blockage. | Gastroenterology | Radiology Report | high |
426 | 75 y/o M with PMH of cirrhosis, s/p THR, GERD, admitted for appendicitis. CT confirmed. Taken to OR for laparoscopic appendectomy. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on sertraline 50mg daily, escitalopram 10mg daily, pregabalin 75mg BID. F/U INR check in 3 days. | A 75-year-old man with a history of liver scarring [cirrhosis], prior hip replacement, and acid reflux was admitted for inflammation of the appendix. CT confirmed. Taken to OR for laparoscopic appendectomy. They were treated according to standard guidelines and improved. Write down your blood sugar readings in a log bo... | General Surgery | Discharge Summary | high |
427 | 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 |
428 | 58 y/o M with PMH of OSA on CPAP, A-fib, HFpEF, CKD Stage 4, anxiety, admitted for sepsis secondary to cellulitis. Blood cultures drawn. IV antibiotics started emergently. Managed per protocol with improvement. Strict I&O, daily weights. D/C on latanoprost 0.005% OU QHS, Eliquis 5mg BID, furosemide 40mg BID, hydroxychl... | A 58-year-old man with a history of sleep apnea [uses a breathing machine at night], irregular heartbeat [atrial fibrillation], heart failure with stiff heart muscle, advanced kidney disease, and anxiety was admitted for a serious blood infection from a skin infection. Blood cultures drawn. IV antibiotics started emerg... | Infectious Disease | Discharge Summary | high |
429 | CXR PA: Left lower lobe consolidation. Cardiomegaly with CTR >0.5. Small left pleural effusion. Widened mediastinum. | Chest X-ray results: There is an area in the lower left lung that appears infected. The heart appears larger than normal. There is a small amount of fluid around the left lung. The space between the lungs appears wider than normal, which needs further evaluation. | Pulmonology | Radiology Report | high |
430 | 84 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 84-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 |
431 | Procedure: EGD with biopsy. Pt 73 y/o F. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes upper endoscopy with small tissue samples taken for a 73-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 |
432 | 76 y/o F with PMH of CHF, cirrhosis, CKD Stage 3, admitted for sepsis secondary to UTI. Blood cultures positive. Lactate elevated. Managed per protocol with improvement. BRAT diet x 48hrs, advance as tolerated. D/C on Eliquis 5mg BID, entresto 49/51mg BID, sertraline 50mg daily, omeprazole 20mg AC breakfast, levothyrox... | A 76-year-old woman with a history of heart failure, liver scarring [cirrhosis], and moderate kidney disease 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... | Infectious Disease | Discharge Summary | high |
433 | Methotrexate 15mg weekly on fixed weekday only; folic acid except MTX day; avoid alcohol. | Take methotrexate only once per week on the same day — never daily. Take folic acid as directed. Avoid alcohol. | Rheumatology | Medication Instruction | low |
434 | 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 |
435 | 81 y/o F presenting to ED with hematemesis x 2 episodes, dark tarry stools x 2 days. Vitals: BP 92/58, HR 122, RR 22, O2 96%. Hgb 6.8 (baseline 13). Type and crossmatch sent. 2 units pRBC transfused. EGD: bleeding duodenal ulcer, treated with epinephrine injection + clips. Dx: Upper GI bleed secondary to duodenal ulcer... | A 81-year-old woman came to the emergency room with vomiting blood twice and having dark, tarry stools for 2 days. Vital signs: blood pressure dangerously low, heart rate very fast (signs of significant blood loss). Blood count dropped severely (6.8, was 13). Two units of blood transfused. Camera test of stomach found ... | Emergency Medicine | Clinical Note | high |
436 | 34 y/o F with PMH of DVT/PE on warfarin, DM2, DM1, admitted for upper GI bleeding. Hematemesis noted. EGD showed bleeding ulcer. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on spironolactone 25mg daily, Eliquis 5mg BID. F/U oncology in 1 week. | A 34-year-old woman with a history of blood clots [on blood thinner warfarin], type 2 diabetes, and type 1 diabetes was admitted for bleeding from the stomach or food pipe. Hematemesis noted. EGD showed bleeding ulcer. They were treated according to standard guidelines and improved. Use the breathing exercise device ev... | Gastroenterology | Discharge Summary | high |
437 | Thyroid panel: TSH 2.25 (N), Free T4 2.7. | Your thyroid test results: TSH is normal at 2.25. Free T4 is normal — your thyroid function is balanced. | Endocrinology | Lab Result | medium |
438 | 27 y/o F with PMH of s/p TKR, hypothyroidism, HTN, GERD, admitted for pyelonephritis. UA showed infection. Flank pain and fever. IV antibiotics started. Managed per protocol with improvement. Strict NPO after midnight before procedure. D/C on furosemide 40mg daily, hydroxychloroquine 200mg BID, losartan 50mg daily, car... | A 27-year-old woman with a history of prior knee replacement, underactive thyroid, high blood pressure, and acid reflux 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 improved. Do not eat o... | Urology | Discharge Summary | high |
439 | MRI Lumbar Spine: No compression fracture. Central canal stenosis at L3-L4. L4-L5 disc herniation with moderate bilateral foraminal stenosis. | 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 L4-L5 level, a disc has pushed outward [herniated] and is narrowing the nerve tunnels on both sides. | Orthopedics | Radiology Report | high |
440 | MRI Lumbar Spine: C5-C6 disc herniation with cord compression. Facet joint hypertrophy at L4-L5. Conus medullaris at L1, normal. | MRI of the lower back results: At C5-C6 in the neck, a disc has pushed out and is pressing on the spinal cord — this is significant. The small joints in the spine at L4-L5 are enlarged from arthritis. The spinal cord ends at a normal level. | Orthopedics | Radiology Report | high |
441 | 42 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 42-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 |
442 | 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 |
443 | 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 | medium |
444 | CT Head without contrast: Chronic lacunar infarcts in bilateral basal ganglia. Acute ischemic infarct in R MCA territory. No acute intracranial hemorrhage. | CT scan of the head results: There are signs of small old strokes in the deep parts of the brain. There is a new stroke affecting the right side of the brain, in the area supplied by the middle cerebral artery. There is no bleeding in the brain. | Neurology | Radiology Report | high |
445 | 23 y/o M with PMH of RA on MTX, depression, PPM in situ, Parkinson's disease, GERD, 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 ibuprofen 400mg Q6H PRN with food, ondansetron 4mg Q8H PRN N/V, cal... | A 23-year-old man with a history of rheumatoid arthritis [on immune-suppressing medicine], depression, implanted pacemaker, Parkinson's disease, and acid reflux was admitted for chest pain being evaluated for a possible heart attack. Serial troponins and cardiac monitoring performed. They were treated according to stan... | Cardiology | Discharge Summary | high |
446 | 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 |
447 | 82 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 82-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 |
448 | Rx: Tab Xarelto 20mg daily with dinner. Tab lisinopril 20mg daily. Tab ondansetron 4mg Q8H PRN N/V. Humalog per SSI. Tab amlodipine 5mg daily. Adv: low salt low sugar diet, regular exercise. F/U PCP in 1 week for BP recheck. | Your medicines: (1) Xarelto 20mg once daily with dinner [blood thinner]. (2) lisinopril 20mg once daily [blood pressure medicine]. (3) ondansetron (Zofran) 4mg every 8 hours as needed [anti-nausea medicine]. (4) Humalog insulin before meals as directed [fast-acting insulin]. (5) amlodipine 5mg once daily [blood pressur... | Cardiology | Prescription | high |
449 | Rx: Tab glipizide 5mg BID AC. Tab metoprolol succinate 50mg daily. Tab sertraline 50mg daily. Tab clopidogrel 75mg daily. Adv: avoid alcohol, hepatotoxic drugs. F/U 1 month with repeat imaging. | Your medicines: (1) glipizide 5mg twice daily before meals [helps release insulin]. (2) metoprolol 50mg once daily [heart rate and blood pressure medicine]. (3) sertraline 50mg once daily [antidepressant/anxiety medicine]. (4) Plavix (clopidogrel) 75mg once daily [blood thinner]. Advice: do not drink alcohol and avoid ... | Cardiology | Prescription | low |
450 | 37 y/o M presenting to ED with sudden onset R-sided weakness, facial droop, slurred speech x 45 min. Vitals: BP 188/102, HR 88, RR 16, O2 97%. CT Head: no hemorrhage. CTA: L MCA occlusion. NIHSS 14. Dx: Acute ischemic stroke, L MCA territory. tPA administered (within 3hr window). Thrombectomy team activated. Admit stro... | A 37-year-old man came to the emergency room with sudden right-sided weakness, face drooping on one side, and slurred speech for 45 minutes. Vital signs: blood pressure very high, heart rate normal, breathing normal, oxygen normal. CT scan ruled out bleeding. Blood vessel scan showed a blocked artery on the left side o... | Emergency Medicine | Clinical Note | high |
451 | 87 y/o M with PMH of HLD, ESRD on HD, asthma, admitted for fall with hip fracture. X-ray confirmed femoral neck fracture. Orthopedics consulted. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on montelukast 10mg QHS, clopidogrel 75mg daily, Augmentin 875/125 BID x 7 days. F/U car... | A 87-year-old man with a history of high cholesterol, kidney failure requiring dialysis, and asthma 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. Write down your blood sugar readings in a log book ... | Orthopedics | Discharge Summary | high |
452 | 39 y/o M with PMH of HLD, depression, admitted for pneumonia. CXR confirmed infiltrate. Started on IV antibiotics. Managed per protocol with improvement. BRAT diet x 48hrs, advance as tolerated. D/C on latanoprost 0.005% OU QHS, clopidogrel 75mg daily, Xarelto 20mg daily with dinner. F/U PCP in 2 weeks. | A 39-year-old man with a history of high cholesterol, and depression was admitted for a lung infection. CXR confirmed infiltrate. Started on IV antibiotics. They were treated according to standard guidelines and improved. Eat bland food for 48 hours (bananas, rice, applesauce, toast), then slowly return to normal diet.... | Pulmonology | Discharge Summary | high |
453 | 24 y/o F presenting to ED with severe epigastric pain radiating to back, N/V x 6hrs. Vitals: BP 138/82, HR 108, RR 20, T 100.4F. Lipase 1800 (H). CT abdomen: peripancreatic fat stranding, no necrosis. Dx: Acute pancreatitis. NPO, aggressive IVF, IV morphine, IV pantoprazole. Admit medicine. | A 24-year-old woman came to the emergency room with severe upper belly pain shooting to the back with nausea and vomiting for 6 hours. Vital signs: blood pressure normal, heart rate fast, mild fever. Pancreas enzyme very high. CT scan showed severe pancreas inflammation but no dead tissue. Diagnosis: severe inflammatio... | Emergency Medicine | Clinical Note | high |
454 | Thyroid panel: TSH 1.29 (N), Free T4 1.9. | Your thyroid test results: TSH is normal at 1.29. Free T4 is normal — your thyroid function is balanced. | Endocrinology | Lab Result | medium |
455 | Lipid panel: TC 245, LDL 215, HDL 80, TG 430. | Your cholesterol results: Total cholesterol is 245. LDL (bad cholesterol) is very high at 215 (goal under 100), significantly increasing heart disease risk. HDL (good cholesterol) is good at 80. Triglycerides are very high at 430 (normal under 150) — increases risk of pancreatitis. | Cardiology | Lab Result | high |
456 | CXR PA: Increased interstitial markings suggesting pulmonary edema. Bilateral hilar lymphadenopathy. Mild cardiomegaly. | Chest X-ray results: There are signs of extra fluid in the lung tissue, suggesting the heart may not be pumping efficiently [pulmonary edema]. There are enlarged lymph nodes at the root of both lungs, which needs further evaluation. The heart is slightly larger than normal. | Pulmonology | Radiology Report | high |
457 | US Abdomen: GB wall thickening with stones, positive Murphy's sign. CBD 12mm, dilated. CBD 5mm, not dilated. | Abdominal ultrasound results: The gallbladder wall is thickened and gallstones are present — pressing on the gallbladder area caused pain [positive Murphy's sign], suggesting infection. The bile duct is wider than normal [dilated], which may indicate a blockage. The bile duct is normal size [not blocked]. | Gastroenterology | Radiology Report | high |
458 | 23 y/o M with PMH of s/p TKR, h/o TIA, obesity (BMI 38), s/p CABG, CHF, admitted for cholecystitis. US showed gallbladder wall thickening and stones. Surgery consulted. Managed per protocol with improvement. Compression stockings when ambulating. D/C on albuterol MDI 2 puffs Q4-6H PRN, metoprolol succinate 50mg daily. ... | A 23-year-old man with a history of prior knee replacement, history of mini-stroke, obesity, prior heart bypass surgery, and heart failure was admitted for gallbladder infection/inflammation. US showed gallbladder wall thickening and stones. Surgery consulted. They were treated according to standard guidelines and impr... | General Surgery | Discharge Summary | high |
459 | CBC: WBC 12.0 (H), Hgb 8.9 (L), Plt 189 (N). | Your blood count results: White blood cells are 12.0 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is low at 8.9, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 189, which is normal. | Hematology | Lab Result | high |
460 | 91 y/o F with PMH of seizure disorder on Keppra, HTN, admitted for appendicitis. CT confirmed. Taken to OR for laparoscopic appendectomy. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on Dulcolax 10mg QHS PRN, calcium + vitamin D 600/400 daily, carvedilol 12.5mg BID, aml... | A 91-year-old woman with a history of seizure disorder [on Keppra], and high blood pressure was admitted for inflammation of the appendix. CT confirmed. Taken to OR for laparoscopic appendectomy. They were treated according to standard guidelines and improved. Use the breathing exercise device every hour while awake. W... | General Surgery | Discharge Summary | high |
461 | LFTs: AST 380 (H), ALT 374 (H), ALP 260, T.Bili 3.8 (H), Albumin 1.5. | Your liver blood test results: Liver enzymes (AST 380, ALT 374) are severely elevated, indicating significant liver damage (normal is under 40). Bilirubin is high at 3.8 (normal under 1.2) — may cause yellowing of skin and eyes [jaundice]. Albumin is low at 1.5 (normal 3.5-5.5), suggesting the liver is struggling to ma... | Gastroenterology | Lab Result | high |
462 | 66 y/o F with PMH of HFrEF (EF 30%), anxiety, s/p THR, admitted for acute CHF exacerbation. BNP elevated. CXR showed pulmonary edema. Managed per protocol with improvement. Strict NPO after midnight before procedure. D/C on latanoprost 0.005% OU QHS, amoxicillin 500mg TID x 10 days. F/U cardiology in 2 weeks. | A 66-year-old woman with a history of heart failure with weak pumping (30%), anxiety, and prior hip replacement 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. Do not eat or drink anything aft... | Cardiology | Discharge Summary | high |
463 | CXR PA: No cardiomegaly. Bilateral hilar lymphadenopathy. Pacemaker leads in appropriate position. Right lower lobe consolidation. Sternotomy wires intact. | Chest X-ray results: The heart is a normal size. There are enlarged lymph nodes at the root of both lungs, which needs further evaluation. The pacemaker wires are in the correct position. There is an area in the lower right lung that appears infected, suggesting pneumonia. The wires from prior heart surgery are intact. | Pulmonology | Radiology Report | high |
464 | 72 y/o F presenting to ED with acute onset pleuritic CP, SOB, R calf swelling x 3 days. Vitals: BP 132/88, HR 112, RR 24, O2 91% on RA. D-dimer elevated. CTA chest: bilateral PE with RV strain. US R LE: popliteal DVT. Dx: Bilateral PE with DVT. Heparin drip started. Consider catheter-directed thrombolysis given RV stra... | A 72-year-old woman came to the emergency room with sudden chest pain that worsens with breathing, shortness of breath, and right calf swelling for 3 days. Vital signs: blood pressure normal, heart rate fast, breathing rapid, oxygen low at 91%. A blood clot screening test was positive. CT scan confirmed blood clots in ... | Emergency Medicine | Clinical Note | high |
465 | CXR PA: No pneumothorax. Right lower lobe consolidation. Mild cardiomegaly. Small left pleural effusion. Elevated left hemidiaphragm. | Chest X-ray results: There is no collapsed lung. There is an area in the lower right lung that appears infected, suggesting pneumonia. The heart is slightly larger than normal. There is a small amount of fluid around the left lung. The left side of the breathing muscle [diaphragm] is sitting higher than normal. | Pulmonology | Radiology Report | high |
466 | 64 y/o M with PMH of HFrEF (EF 30%), COPD, admitted for PE. CTA positive for PE. Heparin started. Managed per protocol with improvement. Low potassium diet. D/C on methotrexate 15mg weekly, Eliquis 5mg BID, calcium + vitamin D 600/400 daily. F/U surgery in 2 weeks for drain removal. | A 64-year-old man with a history of heart failure with weak pumping (30%), and chronic lung disease was admitted for a blood clot in the lungs [pulmonary embolism]. CT scan confirmed a blood clot in the lungs. Heparin started. They were treated according to standard guidelines and improved. Avoid high-potassium foods: ... | Pulmonology | Discharge Summary | high |
467 | Rx: Tab clopidogrel 75mg daily. Tab lisinopril 10mg daily. Tab potassium chloride 20mEq daily. Tab ferrous sulfate 325mg BID. Tab furosemide 40mg daily. Adv: elevate affected limb, compression stockings Adv: low salt diet, fluid restriction 1.5L/day. F/U PCP in 1 week for BP recheck. | Your medicines: (1) Plavix (clopidogrel) 75mg once daily [blood thinner]. (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) iron supplement 325mg twice daily [for low blood count — take with vita... | Cardiology | Prescription | high |
468 | Delivery Note: G?P? at 39+1 weeks. SVD. Live female infant. APGAR 9/9. 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 9/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
469 | CT Head without contrast: Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. No acute intracranial hemorrhage. No midline shift. No mass effect. | CT scan of the head results: There are aging-related changes in the brain's white matter from reduced blood flow to small vessels over time. There is no bleeding in the brain. The brain is centered normally. There are no tumors or masses pushing on the brain. | Neurology | Radiology Report | high |
470 | 47 y/o M presenting to ED with fall from standing, R hip pain, unable to bear weight. Vitals: BP 142/78, HR 88, RR 16, O2 97%. X-ray pelvis: displaced R femoral neck fracture. Pre-op labs WNL. ECG: NSR. Dx: R femoral neck fracture. Pain management with IV morphine. NPO for OR. Ortho consult for hemiarthroplasty vs ORIF... | A 47-year-old man came to the emergency room with fell from standing, severe right hip pain, unable to put weight on the right leg. Vital signs: blood pressure slightly high (pain), heart rate normal, breathing normal, oxygen normal. X-ray showed a broken hip bone (displaced femoral neck fracture) on the right side. Pr... | Emergency Medicine | Clinical Note | high |
471 | MRI Lumbar Spine: Multilevel degenerative disc disease. L5-S1 disc desiccation with mild bulge. No compression fracture. L4-L5 disc herniation with moderate bilateral foraminal stenosis. | MRI of the lower back results: Multiple discs in the spine are showing wear and aging. At the L5-S1 level, the disc is dried out [worn] with a slight bulge, but not causing significant pressure. No bones are broken or collapsed. At the L4-L5 level, a disc has pushed outward [herniated] and is narrowing the nerve tunnel... | Orthopedics | Radiology Report | high |
472 | CBC: WBC 3.3 (L), Hgb 15.6 (N), Plt 389 (N). | Your blood count results: White blood cells are 3.3 (low, meaning your immune system may be weakened). Hemoglobin is normal at 15.6. Platelets are 389, which is normal. | Hematology | Lab Result | high |
473 | CXR PA: Osseous structures intact. Bilateral pleural effusions. Hyperinflated lungs consistent with COPD. Increased interstitial markings suggesting pulmonary edema. Moderate right pleural effusion. | Chest X-ray results: The bones look normal with no fractures. There is fluid collecting around both lungs. The lungs appear over-inflated, which is typical of chronic lung disease [COPD/emphysema]. There are signs of extra fluid in the lung tissue, suggesting the heart may not be pumping efficiently [pulmonary edema]. ... | Pulmonology | Radiology Report | high |
474 | CBC: WBC 19.8 (H), Hgb 11.3 (L), Plt 213 (N). | Your blood count results: White blood cells are 19.8 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is low at 11.3, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 213, which is normal. | Hematology | Lab Result | high |
475 | CBC: WBC 21.2 (H), Hgb 17.3 (H), Plt 103 (L). | Your blood count results: White blood cells are 21.2 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is elevated at 17.3. Platelets are 103, which is low — your blood may not clot properly, increasing bleeding risk. | Hematology | Lab Result | high |
476 | 79 y/o F with PMH of cirrhosis, A-fib, PPM in situ, anemia, admitted for HHS. Blood sugar >800. Severe dehydration. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on prednisone taper, Eliquis 5mg BID, Xarelto 20mg daily with dinner. F/U PCP in 2 weeks. | A 79-year-old woman with a history of liver scarring [cirrhosis], irregular heartbeat [atrial fibrillation], implanted pacemaker, and low blood count [anemia] was admitted for hyperosmolar hyperglycemic state [extremely high blood sugar]. Blood sugar >800. Severe dehydration. They were treated according to standard gui... | Endocrinology | Discharge Summary | high |
477 | 53 y/o F with PMH of PAD, ICD in situ, DM2, h/o CVA, COPD, admitted for acute pancreatitis. Lipase markedly elevated. CT showed peripancreatic inflammation. Managed per protocol with improvement. Compression stockings when ambulating. D/C on ASA 81mg daily, azithromycin 500mg day 1 then 250mg x 4 days. F/U nephrology i... | A 53-year-old woman with a history of poor blood flow in the legs [peripheral artery disease], implanted heart defibrillator, type 2 diabetes, history of stroke, and chronic lung disease was admitted for severe inflammation of the pancreas. A pancreas enzyme was very high. CT scan showed peripancreatic inflammation. Th... | Gastroenterology | Discharge Summary | high |
478 | CBC: WBC 23.2 (H), Hgb 7.1 (L), Plt 122 (L). | Your blood count results: White blood cells are 23.2 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is low at 7.1, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 122, which is low — your blood may not clot properly, increasing bl... | Hematology | Lab Result | high |
479 | 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 |
480 | 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 |
481 | Rx: Tab ondansetron 4mg Q8H PRN N/V. Tab losartan 50mg daily. Tab methotrexate 15mg weekly. Avoid grapefruit juice Adv: avoid alcohol, hepatotoxic drugs. F/U 2 weeks. | Your medicines: (1) ondansetron (Zofran) 4mg every 8 hours as needed [anti-nausea medicine]. (2) losartan 50mg once daily [blood pressure medicine]. (3) methotrexate 15mg once weekly [immune-suppressing medicine for arthritis — requires monitoring]. Do not drink grapefruit juice as it interferes with this medication Ad... | Cardiology | Prescription | medium |
482 | Procedure: PCI with DES to LAD. Pt 33 y/o M. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes heart catheter procedure to place a stent in a heart artery for a 33-year-old man. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | Cardiology | Procedure Note | high |
483 | Lipid panel: TC 313, LDL 219, HDL 38, TG 425. | Your cholesterol results: Total cholesterol is 313. LDL (bad cholesterol) is very high at 219 (goal under 100), significantly increasing heart disease risk. HDL (good cholesterol) is too low at 38 (should be above 40 for men, 50 for women) — this is a risk factor for heart disease. Triglycerides are very high at 425 (n... | Cardiology | Lab Result | high |
484 | Enoxaparin 40mg SC daily until walking regularly. | Injection helps prevent clots until you are walking normally. | General | Medication Instruction | medium |
485 | 79 y/o F with PMH of h/o CVA, PPM in situ, CKD Stage 3, HFrEF (EF 30%), PAD, admitted for appendicitis. CT confirmed. Taken to OR for laparoscopic appendectomy. Managed per protocol with improvement. Head injury precautions x 48hrs. D/C on acetaminophen 650mg Q6H PRN, gabapentin 300mg TID, rosuvastatin 10mg QHS, calciu... | A 79-year-old woman with a history of history of stroke, implanted pacemaker, moderate kidney disease, heart failure with weak pumping (30%), and poor blood flow in the legs [peripheral artery disease] was admitted for inflammation of the appendix. CT confirmed. Taken to OR for laparoscopic appendectomy. They were trea... | General Surgery | Discharge Summary | high |
486 | MRI Lumbar Spine: No compression fracture. Central canal stenosis at L3-L4. Multilevel degenerative disc disease. Conus medullaris at L1, normal. | 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. Multiple discs in the spine are showing wear and aging. The spinal cord ends at a normal level. | Orthopedics | Radiology Report | high |
487 | Rx: Tab rosuvastatin 10mg QHS. Tab amlodipine 10mg daily. Adv: SMBG BID, diabetic diet Do not stop abruptly, taper as directed. F/U 1 week with CBC, CMP. | Your medicines: (1) rosuvastatin 10mg at bedtime [cholesterol medicine]. (2) amlodipine 10mg once daily [blood pressure medicine]. Advice: check your blood sugar twice daily and follow a diabetes-friendly diet Do not suddenly stop this medicine — your doctor will gradually reduce the dose if needed. Come back in 1 week... | Cardiology | Prescription | medium |
488 | MRI Lumbar Spine: Conus medullaris at L1, normal. L4-L5 disc herniation with moderate bilateral foraminal stenosis. C5-C6 disc herniation with cord compression. | MRI of the lower back results: The spinal cord ends at a normal level. At the L4-L5 level, a disc has pushed outward [herniated] and is narrowing the nerve tunnels on both sides. At C5-C6 in the neck, a disc has pushed out and is pressing on the spinal cord — this is significant. | Orthopedics | Radiology Report | high |
489 | Rx: Tab methotrexate 15mg weekly. Lantus 20U QHS. Tab calcium + vitamin D 600/400 daily. Adv: low salt diet, fluid restriction 1.5L/day Adv: weight bearing exercise, calcium/vit D supplementation. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT. | Your medicines: (1) methotrexate 15mg once weekly [immune-suppressing medicine for arthritis — requires monitoring]. (2) Lantus insulin 20 units at bedtime [long-acting insulin]. (3) calcium plus vitamin D once daily [bone strengthening]. Advice: eat less salt and limit your total fluid intake to about 6 cups per day A... | Endocrinology | Prescription | medium |
490 | US Abdomen: CBD 12mm, dilated. Right kidney 10.5cm, no hydronephrosis. GB wall thickening with stones, positive Murphy's sign. No focal hepatic lesion. Moderate right hydronephrosis. Pancreas unremarkable. | Abdominal ultrasound results: The bile duct is wider than normal [dilated], which may indicate a blockage. Right kidney is normal size with no blockage. The gallbladder wall is thickened and gallstones are present — pressing on the gallbladder area caused pain [positive Murphy's sign], suggesting infection. No tumors o... | Gastroenterology | Radiology Report | high |
491 | CBC: WBC 22.1 (H), Hgb 10.7 (L), Plt 423 (H). | Your blood count results: White blood cells are 22.1 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is low at 10.7, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 423, which is high — your blood may clot too easily. | Hematology | Lab Result | high |
492 | CXR PA: Osseous structures intact. Mild cardiomegaly. Elevated left hemidiaphragm. Cardiomegaly with CTR >0.5. | Chest X-ray results: The bones look normal with no fractures. The heart is slightly larger than normal. The left side of the breathing muscle [diaphragm] is sitting higher than normal. The heart appears larger than normal. | Pulmonology | Radiology Report | high |
493 | 67 y/o M with PMH of seizure disorder on Keppra, SLE, admitted for alcohol withdrawal. CIWA protocol initiated. Lorazepam given as needed. Managed per protocol with improvement. Daily weights, 1.5L fluid restriction, low sodium diet. D/C on escitalopram 10mg daily, timolol 0.5% OU BID. F/U surgery in 2 weeks for drain ... | A 67-year-old man with a history of seizure disorder [on Keppra], and lupus was admitted for withdrawal symptoms after stopping alcohol. CIWA protocol initiated. Lorazepam given as needed. They were treated according to standard guidelines and improved. Weigh yourself every morning before eating. Limit fluids to about ... | Psychiatry | Discharge Summary | high |
494 | 43 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 43-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 |
495 | Thyroid panel: TSH 1.38 (N), Free T4 1.7. | Your thyroid test results: TSH is normal at 1.38. Free T4 is normal — your thyroid function is balanced. | Endocrinology | Lab Result | medium |
496 | Rx: Tab montelukast 10mg QHS. Tab furosemide 40mg BID. prednisone taper. Tab ciprofloxacin 500mg BID x 5 days. Tab entresto 49/51mg BID. Adv: low potassium diet. F/U INR in 3 days. | Your medicines: (1) montelukast 10mg at bedtime [asthma/allergy medicine]. (2) furosemide (Lasix) 40mg twice daily [water pill]. (3) prednisone steroid — dose gradually decreases as directed [do not stop suddenly]. (4) ciprofloxacin 500mg twice daily for 5 days [antibiotic — avoid dairy within 2 hours]. (5) Entresto 49... | Cardiology | Prescription | high |
497 | Warfarin 5mg PO daily. INR goal 2.0-3.0. Avoid major diet changes in vitamin K. Report bleeding. | Take warfarin daily. Blood tests keep clotting in a safe range. Keep vitamin K intake steady and call your doctor for unusual bleeding. | Hematology | Medication Instruction | medium |
498 | Thyroid panel: TSH 4.64 (H), Free T4 2.9. | Your thyroid test results: TSH is elevated at 4.64 (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 |
499 | Procedure: EGD with biopsy. Pt 32 y/o F. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes upper endoscopy with small tissue samples taken for a 32-year-old woman. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | Gastroenterology | Procedure Note | high |
500 | Thyroid panel: TSH 13.37 (H), Free T4 2.8. | Your thyroid test results: TSH is elevated at 13.37 (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 |
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