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4,901 | 50 y/o M with PMH of h/o CVA, CKD Stage 4, PAD, admitted for small bowel obstruction. CT showed dilated loops of bowel with transition point. Managed per protocol with improvement. Head injury precautions x 48hrs. D/C on pantoprazole 40mg AC breakfast, potassium chloride 20mEq daily, Spiriva 18mcg daily, levothyroxine ... | A 50-year-old man with a history of history of stroke, advanced kidney disease, and poor blood flow in the legs [peripheral artery disease] 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. Wa... | General Surgery | Discharge Summary | high |
4,902 | Rx: Tab acetaminophen 650mg Q6H PRN. Tab ferrous sulfate 325mg BID. Tab furosemide 40mg daily. Avoid grapefruit juice Adv: low potassium diet. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT. | Your medicines: (1) Tylenol (acetaminophen) 650mg every 6 hours as needed [do not exceed 3000mg/day]. (2) iron supplement 325mg twice daily [for low blood count — take with vitamin C]. (3) furosemide (Lasix) 40mg once daily [water pill to remove extra fluid]. Do not drink grapefruit juice as it interferes with this med... | General | Prescription | medium |
4,903 | 73 y/o M with PMH of seizure disorder on Keppra, anxiety, HLD, h/o CVA, OA, admitted for alcohol withdrawal. CIWA protocol initiated. Lorazepam given as needed. Managed per protocol with improvement. Wound care: daily dressing changes with wet-to-dry gauze. D/C on metoprolol succinate 50mg daily, warfarin 5mg daily, la... | A 73-year-old man with a history of seizure disorder [on Keppra], anxiety, high cholesterol, history of stroke, 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.... | Psychiatry | Discharge Summary | high |
4,904 | 66 y/o M with PMH of HFrEF (EF 30%), s/p CABG, cirrhosis, admitted for pyelonephritis. UA showed infection. Flank pain and fever. IV antibiotics started. Managed per protocol with improvement. BRAT diet x 48hrs, advance as tolerated. D/C on ondansetron 4mg Q8H PRN N/V, Eliquis 5mg BID. F/U INR check in 3 days. | A 66-year-old man with a history of heart failure with weak pumping (30%), prior heart bypass surgery, and liver scarring [cirrhosis] 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... | Urology | Discharge Summary | high |
4,905 | 83 y/o M with PMH of HFrEF (EF 30%), CHF, admitted for hypertensive urgency. BP 210/120. IV medications started to lower gradually. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on losartan 50mg daily, Augmentin 875/125 BID x 7 days, ibuprofen 400mg Q6H PRN with food. F/... | A 83-year-old man with a history of heart failure with weak pumping (30%), and heart failure was admitted for dangerously high blood pressure. BP 210/120. IV medications started to lower gradually. They were treated according to standard guidelines and improved. Use the breathing exercise device every hour while awake.... | Cardiology | Discharge Summary | high |
4,906 | US Abdomen: Spleen 16cm, splenomegaly. Right kidney 10.5cm, no hydronephrosis. Moderate right hydronephrosis. | Abdominal ultrasound results: The spleen is enlarged [splenomegaly]. Right kidney is normal size with no blockage. The right kidney is swollen because urine is backing up [hydronephrosis], possibly from a blockage. | Gastroenterology | Radiology Report | high |
4,907 | Rx: Tab furosemide 40mg daily. Tab calcium + vitamin D 600/400 daily. Tab Xarelto 20mg daily with dinner. Adv: smoking cessation, pulmonary rehab Adv: elevate affected limb, compression stockings. F/U 6 weeks with LFTs. | Your medicines: (1) furosemide (Lasix) 40mg once daily [water pill to remove extra fluid]. (2) calcium plus vitamin D once daily [bone strengthening]. (3) Xarelto 20mg once daily with dinner [blood thinner]. Advice: stop smoking (ask about nicotine patches or gum) and attend lung rehabilitation program Advice: keep the... | Cardiology | Prescription | medium |
4,908 | Procedure: TURP for BPH. Pt 61 y/o M. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes scope surgery to trim enlarged prostate tissue for a 61-year-old man. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | Urology | Procedure Note | high |
4,909 | Rx: Tab omeprazole 20mg AC breakfast. Tab hydroxychloroquine 200mg BID. Adv: high fiber diet, adequate hydration. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT. | Your medicines: (1) omeprazole 20mg before breakfast [acid-reducing medicine]. (2) hydroxychloroquine 200mg twice daily [immune-modulating medicine — eye exams needed]. Advice: eat plenty of fiber (fruits, vegetables, whole grains) and drink enough water. Come back in 2 weeks with blood tests for: fasting blood sugar [... | Gastroenterology | Prescription | medium |
4,910 | Insulin lispro: count carbs and match units per sliding scale; treat lows per rule. | Fast-acting insulin dosing follows carbohydrate counting and your prescribed sliding scale; treat low blood sugar using your education handout. | Endocrinology | Medication Instruction | medium |
4,911 | CT Head without contrast: Subarachnoid hemorrhage in bilateral sylvian fissures. No mass effect. Paranasal sinuses clear. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. 4cm right subdural hematoma with 5mm midline shift. | CT scan of the head results: There is bleeding around the brain surface, particularly in the grooves on both sides. There are no tumors or masses pushing on the brain. The sinuses are clear with no infection. There are aging-related changes in the brain's white matter from reduced blood flow to small vessels over time.... | Neurology | Radiology Report | high |
4,912 | CBC: WBC 20.0 (H), Hgb 12.0 (N), Plt 34 (L). | Your blood count results: White blood cells are 20.0 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is normal at 12.0. Platelets are 34, which is low — your blood may not clot properly, increasing bleeding risk. | Hematology | Lab Result | high |
4,913 | 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 |
4,914 | 59 y/o F presenting to ED with severe allergic reaction after eating shellfish, diffuse urticaria, lip/tongue swelling, wheezing. Vitals: BP 82/50, HR 132, RR 28, O2 90%. Clinical diagnosis of anaphylaxis based on exam. Dx: Anaphylaxis. Epinephrine 0.3mg IM x 2 doses. IV NS 2L bolus. IV methylprednisolone 125mg. IV dip... | A 59-year-old woman came to the emergency room with severe allergic reaction after eating shellfish — hives all over body, lips and tongue swelling, wheezing. Vital signs: blood pressure dangerously low (shock), heart rate very fast, breathing rapid, oxygen low. Examination and vital signs support a severe systemic all... | Emergency Medicine | Clinical Note | high |
4,915 | HbA1c: 8.0% (H). FBS: 82 mg/dL (N). | Your diabetes blood test results: HbA1c is 8.0%, which is high, meaning your blood sugar has been poorly controlled over the past 3 months (target is under 7%). Fasting blood sugar was 82, which is normal (normal is 70-100). Your diabetes treatment needs to be changed. This level increases risk of complications. | Endocrinology | Lab Result | high |
4,916 | Rx: prednisone taper. Tab glipizide 5mg BID AC. Spiriva 18mcg daily. Tab amlodipine 5mg daily. Adv: high fiber diet, adequate hydration Adv: low potassium diet. F/U PCP in 1 week for BP recheck. | Your medicines: (1) prednisone steroid — dose gradually decreases as directed [do not stop suddenly]. (2) glipizide 5mg twice daily before meals [helps release insulin]. (3) Spiriva inhaler once daily [long-acting lung medicine]. (4) amlodipine 5mg once daily [blood pressure medicine]. Advice: eat plenty of fiber (frui... | Cardiology | Prescription | high |
4,917 | Procedure: Colonoscopy with polypectomy. Pt 39 y/o M. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes colon exam with removal of polyps for a 39-year-old man. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | Gastroenterology | Procedure Note | high |
4,918 | Rx: Tab metformin 500mg BID. Tab amlodipine 10mg daily. Tab metoprolol 25mg BID. Do not stop abruptly, taper as directed Adv: high fiber diet, adequate hydration. F/U 1 week with CBC, CMP. | Your medicines: (1) metformin 500mg twice daily with meals [blood sugar medicine]. (2) amlodipine 10mg once daily [blood pressure medicine]. (3) metoprolol 25mg twice daily [slows heart rate and lowers blood pressure]. Do not suddenly stop this medicine — your doctor will gradually reduce the dose if needed Advice: eat... | Cardiology | Prescription | medium |
4,919 | LFTs: AST 167 (H), ALT 147 (H), ALP 191, T.Bili 2.9 (H), Albumin 2.4. | Your liver blood test results: Liver enzymes (AST 167, ALT 147) are moderately elevated, indicating liver irritation (normal is under 40). Bilirubin is high at 2.9 (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 make imp... | Gastroenterology | Lab Result | high |
4,920 | 65 y/o M presenting to ED with acute onset pleuritic CP, SOB, R calf swelling x 3 days. Vitals: BP 132/88, HR 112, RR 24, O2 91% on RA. D-dimer elevated. CTA chest: bilateral PE with RV strain. US R LE: popliteal DVT. Dx: Bilateral PE with DVT. Heparin drip started. Consider catheter-directed thrombolysis given RV stra... | A 65-year-old man came to the emergency room with sudden chest pain that worsens with breathing, shortness of breath, and right calf swelling for 3 days. Vital signs: blood pressure normal, heart rate fast, breathing rapid, oxygen low at 91%. A blood clot screening test was positive. CT scan confirmed blood clots in bo... | Emergency Medicine | Clinical Note | high |
4,921 | 80 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 80-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 |
4,922 | Rx: Tab potassium chloride 20mEq daily. Tab ferrous sulfate 325mg BID. Tab pregabalin 75mg BID. Adv: low salt diet, fluid restriction 1.5L/day. F/U PCP in 1 week for BP recheck. | Your medicines: (1) potassium supplement 20mEq once daily [replaces potassium lost from water pills]. (2) iron supplement 325mg twice daily [for low blood count — take with vitamin C]. (3) pregabalin 75mg twice daily [nerve pain medicine]. Advice: eat less salt and limit your total fluid intake to about 6 cups per day.... | General | Prescription | medium |
4,923 | Procedure: Laparoscopic cholecystectomy. Pt 28 y/o M. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes minimally invasive gallbladder removal for a 28-year-old man. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | General Surgery | Procedure Note | high |
4,924 | 69 y/o M with PMH of PAD, OSA on CPAP, osteoporosis, Parkinson's disease, HFrEF (EF 30%), admitted for GI bleeding. Hemoglobin dropped. Required blood transfusion. Managed per protocol with improvement. Wound care: daily dressing changes with wet-to-dry gauze. D/C on omeprazole 20mg AC breakfast, montelukast 10mg QHS, ... | A 69-year-old man with a history of poor blood flow in the legs [peripheral artery disease], sleep apnea [uses a breathing machine at night], weak bones [osteoporosis], Parkinson's disease, and heart failure with weak pumping (30%) was admitted for bleeding in the digestive tract. Blood count dropped. Required blood tr... | Gastroenterology | Discharge Summary | high |
4,925 | CXR PA: No pneumothorax. Widened mediastinum. Elevated left hemidiaphragm. | Chest X-ray results: There is no collapsed lung. The space between the lungs appears wider than normal, which needs further evaluation. The left side of the breathing muscle [diaphragm] is sitting higher than normal. | Pulmonology | Radiology Report | high |
4,926 | 55 y/o F with PMH of CKD Stage 4, GERD, seizure disorder on Keppra, depression, admitted for DKA. Blood sugar >500. pH 7.1. Anion gap elevated. Managed per protocol with improvement. Wound care: daily dressing changes with wet-to-dry gauze. D/C on sertraline 50mg daily, Spiriva 18mcg daily, tramadol 50mg Q6H PRN pain. ... | A 55-year-old woman with a history of advanced kidney disease, acid reflux, seizure disorder [on Keppra], and depression was admitted for diabetic ketoacidosis [dangerously high blood sugar with acid buildup]. Blood sugar >500. blood became dangerously acidic. Anion gap elevated. They were treated according to standard... | Endocrinology | Discharge Summary | high |
4,927 | Rx: Tab Augmentin 875/125 BID x 7 days. Tab lisinopril 20mg daily. Adv: elevate affected limb, compression stockings. F/U 1 week with wound check. | Your medicines: (1) Augmentin 875mg twice daily for 7 days [antibiotic]. (2) lisinopril 20mg once daily [blood pressure medicine]. Advice: keep the affected leg elevated when resting and wear compression stockings. Come back in 1 week to have the wound checked. | Cardiology | Prescription | medium |
4,928 | CXR PA: Pacemaker leads in appropriate position. NG tube tip in stomach. Left lower lobe consolidation. Patchy bilateral infiltrates. Increased interstitial markings suggesting pulmonary edema. | Chest X-ray results: The pacemaker wires are in the correct position. The feeding/drainage tube tip is correctly positioned in the stomach. There is an area in the lower left lung that appears infected. There are scattered cloudy patches in both lungs suggesting infection or inflammation. There are signs of extra fluid... | Pulmonology | Radiology Report | high |
4,929 | Rivaroxaban 15mg BID x 21d then 20mg daily with food for PE. | Blood thinner dosing changes after the first 3 weeks — always take with food as instructed for lung clots. | Pulmonology | Medication Instruction | high |
4,930 | Thyroid panel: TSH 1.43 (N), Free T4 2.4. | Your thyroid test results: TSH is normal at 1.43. Free T4 is normal — your thyroid function is balanced. | Endocrinology | Lab Result | medium |
4,931 | 44 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 44-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 |
4,932 | Procedure: TURP for BPH. Pt 87 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 87-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 |
4,933 | CXR PA: Compression fracture T12. Port-a-cath in appropriate position. Left lower lobe consolidation. | Chest X-ray results: There is a compression fracture [collapsed bone] in the lower spine at T12. 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 |
4,934 | Thyroid panel: TSH 3.6 (N), Free T4 1.5. | Your thyroid test results: TSH is normal at 3.6. Free T4 is normal — your thyroid function is balanced. | Endocrinology | Lab Result | medium |
4,935 | CT Head without contrast: Paranasal sinuses clear. Acute ischemic infarct in R MCA territory. No midline shift. 4cm right subdural hematoma with 5mm midline shift. No mass effect. | CT scan of the head results: The sinuses are clear with no infection. There is a new stroke affecting the right side of the brain, in the area supplied by the middle cerebral artery. The brain is centered normally. There is a significant blood collection (4cm) on the right side between the brain and skull, pushing the ... | Neurology | Radiology Report | high |
4,936 | 70 y/o M with PMH of OSA on CPAP, HFpEF, admitted for small bowel obstruction. CT showed dilated loops of bowel with transition point. Managed per protocol with improvement. Strict NPO after midnight before procedure. D/C on amoxicillin 500mg TID x 10 days, latanoprost 0.005% OU QHS, timolol 0.5% OU BID, sertraline 50m... | A 70-year-old man with a history of sleep apnea [uses a breathing machine at night], and heart failure with stiff heart muscle 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. Do not eat or d... | General Surgery | Discharge Summary | high |
4,937 | Delivery Note: G?P? at 38+2 weeks. SVD. Live female infant. APGAR 8/9. EBL within expected limits. Mother stable. | Birth summary: pregnancy reached about 38+2 weeks gestation. The baby was delivered by normal vaginal delivery. The newborn is a healthy female. APGAR scores were 8/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
4,938 | 38 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 38-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 |
4,939 | 40 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 40-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 |
4,940 | Delivery Note: G?P? at 37+3 weeks. SVD. Live male infant. APGAR 8/9. 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 8/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
4,941 | MRI Lumbar Spine: L5-S1 disc desiccation with mild bulge. C5-C6 disc herniation with cord compression. 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. At C5-C6 in the neck, a disc has pushed out and is pressing on the spinal cord — this is significant. No bones are broken or collapsed. | Orthopedics | Radiology Report | high |
4,942 | 67 y/o M with PMH of PAD, OA, HTN, ESRD on HD, Parkinson's disease, admitted for PE. CTA positive for PE. Heparin started. Managed per protocol with improvement. Strict NPO after midnight before procedure. D/C on Eliquis 5mg BID, ferrous sulfate 325mg BID, montelukast 10mg QHS. F/U hematology in 2 weeks. | A 67-year-old man with a history of poor blood flow in the legs [peripheral artery disease], arthritis [osteoarthritis], high blood pressure, kidney failure requiring dialysis, and Parkinson's disease was admitted for a blood clot in the lungs [pulmonary embolism]. CT scan confirmed a blood clot in the lungs. Heparin s... | Pulmonology | Discharge Summary | high |
4,943 | Rx: Tab metformin 500mg BID. Tab methotrexate 15mg weekly. Tab furosemide 40mg BID. Tab escitalopram 10mg daily. Adv: DASH diet, daily BP monitoring. F/U 1 month with repeat imaging. | Your medicines: (1) metformin 500mg twice daily with meals [blood sugar medicine]. (2) methotrexate 15mg once weekly [immune-suppressing medicine for arthritis — requires monitoring]. (3) furosemide (Lasix) 40mg twice daily [water pill]. (4) escitalopram 10mg once daily [antidepressant/anxiety medicine]. Advice: follow... | Cardiology | Prescription | high |
4,944 | Rivaroxaban 15mg BID x 21d then 20mg daily with food for PE. | Blood thinner dosing changes after the first 3 weeks — always take with food as instructed for lung clots. | Pulmonology | Medication Instruction | high |
4,945 | 72 y/o F with PMH of h/o CVA, Parkinson's disease, obesity (BMI 38), CAD, HFpEF, admitted for small bowel obstruction. CT showed dilated loops of bowel with transition point. Managed per protocol with improvement. Strict I&O, daily weights. D/C on spironolactone 25mg daily, potassium chloride 20mEq daily, glipizide 5mg... | A 72-year-old woman with a history of history of stroke, Parkinson's disease, obesity, coronary artery disease [heart artery blockages], and heart failure with stiff heart muscle was admitted for a blockage in the small intestine. CT scan showed dilated loops of bowel with transition point. They were treated according ... | General Surgery | Discharge Summary | high |
4,946 | Procedure: ERCP with sphincterotomy. 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 procedure to open the bile duct using a scope 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. | Gastroenterology | Procedure Note | high |
4,947 | BMP: Na 125 (L), K 5.6 (H), BUN 49, Cr 1.5 (H), Glucose 220. | Your blood chemistry results: Sodium is low at 125 (normal 136-145), meaning too much water in your body. Potassium is dangerously high at 5.6 (normal 3.5-5.0) — this can affect your heart and needs immediate treatment. Creatinine is mildly elevated at 1.5. Blood sugar is 220 (high). | Nephrology | Lab Result | high |
4,948 | Rx: Tab amlodipine 5mg daily. Tab potassium chloride 20mEq daily. Adv: smoking cessation, pulmonary rehab. F/U 1 week with CBC, CMP. | Your medicines: (1) amlodipine 5mg once daily [blood pressure medicine]. (2) potassium supplement 20mEq once daily [replaces potassium lost from water pills]. Advice: stop smoking (ask about nicotine patches or gum) and attend lung rehabilitation program. Come back in 1 week for blood tests: complete blood count [CBC] ... | Cardiology | Prescription | medium |
4,949 | Procedure: PCI with DES to LAD. Pt 24 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 24-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 |
4,950 | Procedure: Port-a-cath placement. Pt 31 y/o M. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes implanted vein port for chemotherapy for a 31-year-old man. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | Oncology | Procedure Note | high |
4,951 | US Abdomen: Spleen 11cm, normal. Left kidney 8cm, cortical thinning consistent with CKD. Right kidney 10.5cm, no hydronephrosis. CBD 12mm, dilated. Liver 18cm, diffusely echogenic consistent with hepatic steatosis. | Abdominal ultrasound results: The spleen is a normal size. Left kidney is small with thin outer layer, consistent with chronic kidney disease. Right kidney is normal size with no blockage. The bile duct is wider than normal [dilated], which may indicate a blockage. The liver is slightly enlarged and appears brighter th... | Gastroenterology | Radiology Report | high |
4,952 | HbA1c: 10.3% (H). FBS: 173 mg/dL (H). | Your diabetes blood test results: HbA1c is 10.3%, which is very high, meaning blood sugar has been dangerously uncontrolled (target is under 7%). Fasting blood sugar was 173, which is high (normal is 70-100). Urgent medication adjustment needed. Very high risk of diabetes complications at this level. | Endocrinology | Lab Result | high |
4,953 | CXR PA: Right lower lobe consolidation. Right middle lobe atelectasis. Port-a-cath in appropriate position. Clear lung fields bilaterally. | Chest X-ray results: There is an area in the lower right lung that appears infected, suggesting pneumonia. Part of the right lung has partially collapsed [atelectasis], possibly from mucus plugging. The implanted medication port is in the correct position. Both lungs look clear with no problems. | Pulmonology | Radiology Report | high |
4,954 | Rx: Tab ferrous sulfate 325mg BID. Tab atorvastatin 80mg QHS. Humalog per SSI. Tab Dulcolax 10mg QHS PRN. Lantus 20U QHS. Adv: low potassium diet. F/U 1 week with CBC, CMP. | Your medicines: (1) iron supplement 325mg twice daily [for low blood count — take with vitamin C]. (2) atorvastatin 80mg at bedtime [high-dose cholesterol medicine]. (3) Humalog insulin before meals as directed [fast-acting insulin]. (4) Dulcolax 10mg at bedtime as needed [for constipation]. (5) Lantus insulin 20 units... | Pediatrics | Prescription | high |
4,955 | Delivery Note: G?P? at 38+2 weeks. SVD. Live female infant. APGAR 8/9. EBL within expected limits. Mother stable. | Birth summary: pregnancy reached about 38+2 weeks gestation. The baby was delivered by normal vaginal delivery. The newborn is a healthy female. APGAR scores were 8/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
4,956 | 85 y/o F presenting to ED with seizure witnessed by family, GTC x 3 min, postictal x 15 min. Vitals: BP 152/88, HR 98, T 98.6F, GCS 14 (postictal). CT Head: no hemorrhage. BMP: Na 128 (L). Keppra level <5 (subtherapeutic). Known seizure disorder, off meds x 1 week. Dx: Breakthrough seizure secondary to medication nonco... | A 85-year-old woman came to the emergency room with a full-body seizure witnessed by family lasting about 3 minutes, followed by 15 minutes of confusion. Vital signs: blood pressure elevated (from seizure), heart rate slightly fast, no fever, mostly alert but still slightly confused. CT scan shows no bleeding. Sodium i... | Emergency Medicine | Clinical Note | high |
4,957 | 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 | low |
4,958 | CBC: WBC 3.3 (L), Hgb 8.6 (L), Plt 209 (N). | Your blood count results: White blood cells are 3.3 (low, meaning your immune system may be weakened). Hemoglobin is low at 8.6, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 209, which is normal. | Hematology | Lab Result | high |
4,959 | 42 y/o F presenting to ED with RLQ pain x 12hrs, anorexia, low-grade fever. Vitals: BP 128/76, HR 96, T 100.8F. CT abdomen: 9mm dilated appendix with periappendiceal fat stranding, no perforation. Dx: Acute uncomplicated appendicitis. NPO, IV Zosyn. Surgery consulted for laparoscopic appendectomy. Admit surgery. | A 42-year-old woman came to the emergency room with pain in the lower right belly for 12 hours, loss of appetite, and mild fever. Vital signs: blood pressure normal, heart rate slightly fast, mild fever. CT scan showed the appendix is swollen (9mm, normal <6mm) with inflammation around it but no rupture. Diagnosis: app... | Emergency Medicine | Clinical Note | high |
4,960 | CT Head without contrast: Subarachnoid hemorrhage in bilateral sylvian fissures. Chronic lacunar infarcts in bilateral basal ganglia. 4cm right subdural hematoma with 5mm midline shift. | CT scan of the head results: There is bleeding around the brain surface, particularly in the grooves on both sides. There are signs of small old strokes in the deep parts of the brain. There is a significant blood collection (4cm) on the right side between the brain and skull, pushing the brain 5mm to the left — this i... | Neurology | Radiology Report | high |
4,961 | CXR PA: Bilateral pleural effusions. Small left pleural effusion. Widened mediastinum. Bilateral hilar lymphadenopathy. | Chest X-ray results: There is fluid collecting around both lungs. There is a small amount of fluid around the left lung. The space between the lungs appears wider than normal, which needs further evaluation. There are enlarged lymph nodes at the root of both lungs, which needs further evaluation. | Pulmonology | Radiology Report | high |
4,962 | Delivery Note: G?P? at 38+2 weeks. Primary low-transverse C-section. Live male infant. APGAR 9/9. EBL within expected limits. Mother stable. | Birth summary: pregnancy reached about 38+2 weeks gestation. The baby was delivered by C-section through a low horizontal cut on the uterus. The newborn is a healthy male. APGAR scores were 9/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
4,963 | 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 |
4,964 | BMP: Na 142 (N), K 4.4 (N), BUN 63, Cr 6.2 (H), Glucose 184. | Your blood chemistry results: Sodium is normal at 142. Potassium is normal at 4.4. Creatinine is elevated at 6.2 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 184 (high). | Nephrology | Lab Result | high |
4,965 | 43 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 43-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 |
4,966 | Rx: Tab methotrexate 15mg weekly. Tab Xarelto 20mg daily with dinner. Tab azithromycin 500mg day 1 then 250mg x 4 days. Tab amlodipine 10mg daily. Adv: DASH diet, daily BP monitoring Do not stop abruptly, taper as directed. F/U 1 month with repeat imaging. | Your medicines: (1) methotrexate 15mg once weekly [immune-suppressing medicine for arthritis — requires monitoring]. (2) Xarelto 20mg once daily with dinner [blood thinner]. (3) azithromycin: 500mg on day 1, then 250mg for the next 4 days [antibiotic]. (4) amlodipine 10mg once daily [blood pressure medicine]. Advice: f... | Cardiology | Prescription | high |
4,967 | 78 y/o F with PMH of SLE, h/o TIA, anemia, admitted for lower GI bleeding. Bright red blood per rectum. Hemoglobin dropping. Managed per protocol with improvement. Diabetic diet, SMBG BID. D/C on amlodipine 10mg daily, levothyroxine 75mcg daily on empty stomach, hydroxychloroquine 200mg BID, prednisone taper, tramadol ... | A 78-year-old woman with a history of lupus, history of mini-stroke, and low blood count [anemia] was admitted for bleeding from the large intestine. Bright red blood per rectum. Hemoglobin dropping. They were treated according to standard guidelines and improved. Follow a diabetes-friendly diet (limit sweets and refin... | Gastroenterology | Discharge Summary | high |
4,968 | Procedure: Laparoscopic cholecystectomy. Pt 87 y/o M. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes minimally invasive gallbladder removal for a 87-year-old man. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | General Surgery | Procedure Note | high |
4,969 | 37 y/o M with PMH of DVT/PE on warfarin, PPM in situ, DM1, admitted for sepsis secondary to cellulitis. Blood cultures drawn. IV antibiotics started emergently. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on rosuvastatin 10mg QHS, amlodipine 5mg daily, ferrous sulfate ... | A 37-year-old man with a history of blood clots [on blood thinner warfarin], implanted pacemaker, and type 1 diabetes was admitted for a serious blood infection from a skin infection. Blood cultures drawn. IV antibiotics started emergently. They were treated according to standard guidelines and improved. Use the breath... | Infectious Disease | Discharge Summary | high |
4,970 | 30 y/o F with PMH of seizure disorder on Keppra, HFrEF (EF 30%), OA, HTN, RA on MTX, admitted for small bowel obstruction. CT showed dilated loops of bowel with transition point. Managed per protocol with improvement. Strict NPO after midnight before procedure. D/C on amoxicillin 500mg TID x 10 days, acetaminophen 650m... | A 30-year-old woman with a history of seizure disorder [on Keppra], heart failure with weak pumping (30%), arthritis [osteoarthritis], high blood pressure, and rheumatoid arthritis [on immune-suppressing medicine] was admitted for a blockage in the small intestine. CT scan showed dilated loops of bowel with transition ... | General Surgery | Discharge Summary | high |
4,971 | 24 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 24-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 |
4,972 | Rx: Tab metoprolol succinate 50mg daily. Tab azithromycin 500mg day 1 then 250mg x 4 days. Tab warfarin 5mg daily. Adv: avoid alcohol, hepatotoxic drugs. F/U 6 weeks with LFTs. | Your medicines: (1) metoprolol 50mg once daily [heart rate and blood pressure medicine]. (2) azithromycin: 500mg on day 1, then 250mg for the next 4 days [antibiotic]. (3) warfarin 5mg once daily [blood thinner — requires regular INR blood tests]. Advice: do not drink alcohol and avoid medications that can harm the liv... | Cardiology | Prescription | medium |
4,973 | 52 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 52-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 |
4,974 | 52 y/o M with PMH of GERD, DM2, anxiety, admitted for cholecystitis. US showed gallbladder wall thickening and stones. Surgery consulted. Managed per protocol with improvement. Compression stockings when ambulating. D/C on pregabalin 75mg BID, sertraline 50mg daily, Spiriva 18mcg daily, omeprazole 20mg AC breakfast. F/... | A 52-year-old man with a history of acid reflux, type 2 diabetes, and anxiety was admitted for gallbladder infection/inflammation. US showed gallbladder wall thickening and stones. Surgery consulted. They were treated according to standard guidelines and improved. Wear compression stockings on your legs when walking to... | General Surgery | Discharge Summary | high |
4,975 | 88 y/o M with PMH of anemia, hypothyroidism, admitted for pyelonephritis. UA showed infection. Flank pain and fever. IV antibiotics started. Managed per protocol with improvement. Compression stockings when ambulating. D/C on pantoprazole 40mg AC breakfast, Xarelto 20mg daily with dinner, amlodipine 10mg daily, rosuvas... | A 88-year-old man with a history of low blood count [anemia], and underactive thyroid 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. Wear compression stockings on your legs when w... | Urology | Discharge Summary | high |
4,976 | 43 y/o M with PMH of A-fib, RA on MTX, Parkinson's disease, admitted for acute CHF exacerbation. BNP elevated. CXR showed pulmonary edema. Managed per protocol with improvement. Diabetic diet, SMBG BID. D/C on atorvastatin 40mg QHS, Xarelto 20mg daily with dinner, amlodipine 5mg daily, lisinopril 10mg daily. F/U surger... | A 43-year-old man with a history of irregular heartbeat [atrial fibrillation], rheumatoid arthritis [on immune-suppressing medicine], and Parkinson's disease was admitted for worsening heart failure with fluid buildup. BNP elevated. Chest X-ray showed pulmonary edema. They were treated according to standard guidelines ... | Cardiology | Discharge Summary | high |
4,977 | 39 y/o F with PMH of HFrEF (EF 30%), COPD, admitted for GI bleeding. Hemoglobin dropped. Required blood transfusion. Managed per protocol with improvement. Low potassium diet. D/C on hydroxychloroquine 200mg BID, amlodipine 10mg daily. F/U INR check in 3 days. | A 39-year-old woman with a history of heart failure with weak pumping (30%), and chronic lung disease was admitted for bleeding in the digestive tract. Blood count dropped. Required blood transfusion. They were treated according to standard guidelines and improved. Avoid high-potassium foods: bananas, oranges, potatoes... | Gastroenterology | Discharge Summary | high |
4,978 | CBC: WBC 16.8 (H), Hgb 16.5 (N), Plt 318 (N). | Your blood count results: White blood cells are 16.8 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is normal at 16.5. Platelets are 318, which is normal. | Hematology | Lab Result | high |
4,979 | 51 y/o F with PMH of seizure disorder on Keppra, CHF, cirrhosis, GERD, gout, admitted for appendicitis. CT confirmed. Taken to OR for laparoscopic appendectomy. Managed per protocol with improvement. BRAT diet x 48hrs, advance as tolerated. D/C on Lantus 20U QHS, gabapentin 300mg TID, Spiriva 18mcg daily, metoprolol su... | A 51-year-old woman with a history of seizure disorder [on Keppra], heart failure, liver scarring [cirrhosis], acid reflux, and gout was admitted for inflammation of the appendix. CT confirmed. Taken to OR for laparoscopic appendectomy. They were treated according to standard guidelines and improved. Eat bland food for... | General Surgery | Discharge Summary | high |
4,980 | Rx: Tab Augmentin 875/125 BID x 7 days. Tab levothyroxine 75mcg daily on empty stomach. Adv: low potassium diet Adv: avoid alcohol, hepatotoxic drugs. F/U 2 weeks with INR. | Your medicines: (1) Augmentin 875mg twice daily for 7 days [antibiotic]. (2) levothyroxine 75mcg on empty stomach 30 min before breakfast [thyroid medicine]. Advice: avoid high-potassium foods like bananas, oranges, potatoes, and tomatoes Advice: do not drink alcohol and avoid medications that can harm the liver (inclu... | Endocrinology | Prescription | medium |
4,981 | 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 |
4,982 | Procedure: ORIF L distal radius. Pt 67 y/o M. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes surgery to fix a wrist fracture with plate and screws for a 67-year-old man. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | Orthopedics | Procedure Note | high |
4,983 | CBC: WBC 11.7 (H), Hgb 9.4 (L), Plt 249 (N). | Your blood count results: White blood cells are 11.7 (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 249, which is normal. | Hematology | Lab Result | high |
4,984 | Rx: Lantus 20U QHS. Tab ASA 81mg daily. Tab amoxicillin 500mg TID x 10 days. Tab lisinopril 10mg daily. Adv: fall precautions, home safety evaluation. F/U 1 week with CBC, CMP. | Your medicines: (1) Lantus insulin 20 units at bedtime [long-acting insulin]. (2) baby aspirin 81mg once daily [prevents blood clots]. (3) amoxicillin 500mg three times daily for 10 days [antibiotic — complete full course]. (4) lisinopril 10mg once daily [blood pressure medicine that also protects kidneys]. Advice: tak... | Cardiology | Prescription | high |
4,985 | 24 y/o M with PMH of HTN, DVT/PE on warfarin, depression, hypothyroidism, admitted for hypertensive urgency. BP 210/120. IV medications started to lower gradually. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on metoprolol succinate 50mg daily, methotrexate 15mg weekly, latanop... | A 24-year-old man with a history of high blood pressure, blood clots [on blood thinner warfarin], depression, and underactive thyroid was admitted for dangerously high blood pressure. BP 210/120. IV medications started to lower gradually. They were treated according to standard guidelines and improved. Write down your ... | Cardiology | Discharge Summary | high |
4,986 | 53 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 53-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 |
4,987 | CXR PA: Port-a-cath in appropriate position. Patchy bilateral infiltrates. NG tube tip in stomach. Small left pleural effusion. | Chest X-ray results: The implanted medication port is in the correct position. There are scattered cloudy patches in both lungs suggesting infection or inflammation. The feeding/drainage tube tip is correctly positioned in the stomach. There is a small amount of fluid around the left lung. | Pulmonology | Radiology Report | high |
4,988 | 80 y/o M presenting to ED with seizure witnessed by family, GTC x 3 min, postictal x 15 min. Vitals: BP 152/88, HR 98, T 98.6F, GCS 14 (postictal). CT Head: no hemorrhage. BMP: Na 128 (L). Keppra level <5 (subtherapeutic). Known seizure disorder, off meds x 1 week. Dx: Breakthrough seizure secondary to medication nonco... | A 80-year-old man came to the emergency room with a full-body seizure witnessed by family lasting about 3 minutes, followed by 15 minutes of confusion. Vital signs: blood pressure elevated (from seizure), heart rate slightly fast, no fever, mostly alert but still slightly confused. CT scan shows no bleeding. Sodium is ... | Emergency Medicine | Clinical Note | high |
4,989 | MRI Lumbar Spine: No compression fracture. C5-C6 disc herniation with cord compression. Facet joint hypertrophy at L4-L5. Central canal stenosis at L3-L4. | MRI of the lower back results: No bones are broken or collapsed. 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 canal is narrowed at L3-L4, which may be pressing on the nerves. | Orthopedics | Radiology Report | high |
4,990 | LFTs: AST 343 (H), ALT 311 (H), ALP 229, T.Bili 2.4 (H), Albumin 4.8. | Your liver blood test results: Liver enzymes (AST 343, ALT 311) are severely elevated, indicating significant liver damage (normal is under 40). Bilirubin is high at 2.4 (normal under 1.2) — may cause yellowing of skin and eyes [jaundice]. Albumin is normal at 4.8. | Gastroenterology | Lab Result | high |
4,991 | 49 y/o M with PMH of gout, Parkinson's disease, admitted for pyelonephritis. UA showed infection. Flank pain and fever. IV antibiotics started. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on albuterol MDI 2 puffs Q4-6H PRN, lisinopril 20mg daily. F/U PCP in 2 weeks. | A 49-year-old man with a history of gout, and Parkinson's disease 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. Write down your blood sugar readings in a log book and bring it to... | Urology | Discharge Summary | high |
4,992 | 45 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 45-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 |
4,993 | 77 y/o M with PMH of gout, ICD in situ, obesity (BMI 38), admitted for PE. CTA positive for PE. Heparin started. Managed per protocol with improvement. Low potassium diet. D/C on clopidogrel 75mg daily, carvedilol 12.5mg BID. F/U neurology in 2 weeks. | A 77-year-old man with a history of gout, implanted heart defibrillator, and obesity 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: bananas, orange... | Pulmonology | Discharge Summary | high |
4,994 | CXR PA: Moderate right pleural effusion. Compression fracture T12. Sternotomy wires intact. Right-sided pneumothorax. | Chest X-ray results: There is a moderate amount of fluid around the right lung. There is a compression fracture [collapsed bone] in the lower spine at T12. The wires from prior heart surgery are intact. The right lung has partially collapsed due to air leaking into the chest cavity [pneumothorax]. | Pulmonology | Radiology Report | high |
4,995 | CT Head without contrast: Paranasal sinuses clear. Mild generalized cerebral atrophy appropriate for age. No midline shift. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. No acute intracranial hemorrhage. | CT scan of the head results: The sinuses are clear with no infection. There is mild brain shrinkage, which is normal for your age. The brain is centered normally. There are aging-related changes in the brain's white matter from reduced blood flow to small vessels over time. There is no bleeding in the brain. | Neurology | Radiology Report | high |
4,996 | 36 y/o M with PMH of asthma, HFrEF (EF 30%), Parkinson's disease, COPD, admitted for STEMI. ECG showed ST elevation. Troponin markedly elevated. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on gabapentin 300mg TID, carvedilol 12.5mg BID. F/U cardiology in 2 weeks. | A 36-year-old man with a history of asthma, heart failure with weak pumping (30%), Parkinson's disease, and chronic lung disease 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... | Cardiology | Discharge Summary | high |
4,997 | Enoxaparin 40mg SC daily until walking regularly. | Injection helps prevent clots until you are walking normally. | General | Medication Instruction | medium |
4,998 | 46 y/o M with PMH of CKD Stage 3, h/o TIA, admitted for cholecystitis. US showed gallbladder wall thickening and stones. Surgery consulted. Managed per protocol with improvement. Diabetic diet, SMBG BID. D/C on carvedilol 12.5mg BID, ibuprofen 400mg Q6H PRN with food. F/U wound care in 3 days. | A 46-year-old man with a history of moderate kidney disease, and history of mini-stroke was admitted for gallbladder infection/inflammation. US showed gallbladder wall thickening and stones. Surgery consulted. They were treated according to standard guidelines and improved. Follow a diabetes-friendly diet (limit sweets... | General Surgery | Discharge Summary | high |
4,999 | Rx: Tab ferrous sulfate 325mg BID. Tab spironolactone 25mg daily. Tab metformin 1000mg BID. Tab furosemide 40mg BID. Tab atorvastatin 80mg QHS. Adv: fall precautions, home safety evaluation Adv: high fiber diet, adequate hydration. F/U 2 weeks with INR. | Your medicines: (1) iron supplement 325mg twice daily [for low blood count — take with vitamin C]. (2) spironolactone 25mg once daily [heart-protecting water pill]. (3) metformin 1000mg twice daily with meals [blood sugar medicine]. (4) furosemide (Lasix) 40mg twice daily [water pill]. (5) atorvastatin 80mg at bedtime ... | Cardiology | Prescription | high |
5,000 | Rx: Tab latanoprost 0.005% OU QHS. Tab warfarin 5mg daily. Tab montelukast 10mg QHS. Adv: avoid alcohol, hepatotoxic drugs Do not stop abruptly, taper as directed. F/U PCP in 1 week for BP recheck. | Your medicines: (1) latanoprost eye drops in both eyes at bedtime [glaucoma medicine]. (2) warfarin 5mg once daily [blood thinner — requires regular INR blood tests]. (3) montelukast 10mg at bedtime [asthma/allergy medicine]. Advice: do not drink alcohol and avoid medications that can harm the liver (including acetamin... | Pulmonology | Prescription | medium |
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