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601 | Lipid panel: TC 153, LDL 61, HDL 47, TG 203. | Your cholesterol results: Total cholesterol is 153. LDL (bad cholesterol) is at goal (61). HDL (good cholesterol) is good at 47. Triglycerides are high at 203. | Cardiology | Lab Result | high |
602 | MRI Lumbar Spine: L4-L5 disc herniation with moderate bilateral foraminal stenosis. Facet joint hypertrophy at L4-L5. | MRI of the lower back results: At the L4-L5 level, a disc has pushed outward [herniated] and is narrowing the nerve tunnels on both sides. The small joints in the spine at L4-L5 are enlarged from arthritis. | Orthopedics | Radiology Report | high |
603 | 31 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 31-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 |
604 | US Abdomen: No focal hepatic lesion. Simple renal cysts bilaterally. Liver 18cm, diffusely echogenic consistent with hepatic steatosis. CBD 5mm, not dilated. | Abdominal ultrasound results: No tumors or masses were found in the liver. Both kidneys have harmless fluid-filled cysts. The liver is slightly enlarged and appears brighter than normal, indicating fatty liver disease. The bile duct is normal size [not blocked]. | Gastroenterology | Radiology Report | high |
605 | 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 |
606 | Rx: Tab losartan 50mg daily. Tab gabapentin 300mg TID. Tab metformin 1000mg BID. Tab furosemide 40mg daily. Adv: avoid alcohol, hepatotoxic drugs Avoid grapefruit juice. F/U 2 weeks. | Your medicines: (1) losartan 50mg once daily [blood pressure medicine]. (2) gabapentin 300mg three times daily [nerve pain medicine — may cause drowsiness]. (3) metformin 1000mg twice daily with meals [blood sugar medicine]. (4) furosemide (Lasix) 40mg once daily [water pill to remove extra fluid]. Advice: do not drink... | Cardiology | Prescription | high |
607 | 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 |
608 | LFTs: AST 397 (H), ALT 13 (N), ALP 118, T.Bili 1.6 (H), Albumin 3.4. | Your liver blood test results: Liver enzymes (AST 397, ALT 13) are normal (normal is under 40). Bilirubin is mildly elevated at 1.6. Albumin is low at 3.4 (normal 3.5-5.5), suggesting the liver is struggling to make important proteins. | Gastroenterology | Lab Result | high |
609 | MRI Lumbar Spine: L5-S1 disc desiccation with mild bulge. No compression fracture. Conus medullaris at L1, normal. | MRI of the lower back results: At the L5-S1 level, the disc is dried out [worn] with a slight bulge, but not causing significant pressure. No bones are broken or collapsed. The spinal cord ends at a normal level. | Orthopedics | Radiology Report | high |
610 | 22 y/o F presenting to ED with altered mental status, found unresponsive at home. Vitals: BP 88/52, HR 128, RR 8, T 96.2F, O2 88%, GCS 8. Glucose 32 (L). UDS positive for opioids. Narcan 2mg IV x 2 with improvement. Dx: Mixed presentation: hypoglycemia + opioid overdose. D50 IV push, Narcan drip. Monitor for re-sedatio... | A 22-year-old woman came to the emergency room with found unconscious at home, not responding normally. Vital signs: blood pressure dangerously low, heart rate very fast, breathing slow, temperature low, oxygen very low, barely responsive. Blood sugar was dangerously low at 32. Drug screen positive for opioids. Narcan ... | Emergency Medicine | Clinical Note | high |
611 | CXR PA: No pneumothorax. ET tube 3cm above carina. Hyperinflated lungs consistent with COPD. | Chest X-ray results: There is no collapsed lung. The breathing tube is in good position. The lungs appear over-inflated, which is typical of chronic lung disease [COPD/emphysema]. | Pulmonology | Radiology Report | high |
612 | MRI Lumbar Spine: No compression fracture. Conus medullaris at L1, normal. | MRI of the lower back results: No bones are broken or collapsed. The spinal cord ends at a normal level. | Orthopedics | Radiology Report | high |
613 | Rx: Tab ASA 81mg daily. Tab timolol 0.5% OU BID. Adv: wound care with daily dressing changes. F/U 2 weeks with INR. | Your medicines: (1) baby aspirin 81mg once daily [prevents blood clots]. (2) timolol eye drops in both eyes twice daily [lowers eye pressure for glaucoma]. Advice: change the wound dressing once daily — clean with saline, apply ointment, cover with fresh bandage. Come back in 2 weeks for a blood thinner level check [IN... | Cardiology | Prescription | medium |
614 | CBC: WBC 5.9 (N), Hgb 7.9 (L), Plt 323 (N). | Your blood count results: White blood cells are 5.9 (normal). Hemoglobin is low at 7.9, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 323, which is normal. | Hematology | Lab Result | high |
615 | CT Head without contrast: No mass effect. Paranasal sinuses clear. No midline shift. | CT scan of the head results: There are no tumors or masses pushing on the brain. The sinuses are clear with no infection. The brain is centered normally. | Neurology | Radiology Report | high |
616 | CT Head without contrast: No acute intracranial hemorrhage. Chronic lacunar infarcts in bilateral basal ganglia. Mild generalized cerebral atrophy appropriate for age. | CT scan of the head results: There is no bleeding in the brain. There are signs of small old strokes in the deep parts of the brain. There is mild brain shrinkage, which is normal for your age. | Neurology | Radiology Report | high |
617 | Rx: Tab warfarin 5mg daily. prednisone taper. Tab clopidogrel 75mg daily. Tab lisinopril 10mg daily. Adv: low potassium diet Adv: avoid alcohol, hepatotoxic drugs. F/U INR in 3 days. | Your medicines: (1) warfarin 5mg once daily [blood thinner — requires regular INR blood tests]. (2) prednisone steroid — dose gradually decreases as directed [do not stop suddenly]. (3) Plavix (clopidogrel) 75mg once daily [blood thinner]. (4) lisinopril 10mg once daily [blood pressure medicine that also protects kidne... | Cardiology | Prescription | high |
618 | 53 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 53-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 |
619 | 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 |
620 | Rx: Tab timolol 0.5% OU BID. Tab empagliflozin 10mg daily. Tab hydroxychloroquine 200mg BID. Tab carvedilol 12.5mg BID. Tab acetaminophen 650mg Q6H PRN. Adv: high fiber diet, adequate hydration Do not stop abruptly, taper as directed. F/U 2 weeks. | Your medicines: (1) timolol eye drops in both eyes twice daily [lowers eye pressure for glaucoma]. (2) empagliflozin 10mg once daily [blood sugar medicine that also protects heart and kidneys]. (3) hydroxychloroquine 200mg twice daily [immune-modulating medicine — eye exams needed]. (4) carvedilol 12.5mg twice daily [h... | Cardiology | Prescription | high |
621 | Rivaroxaban 15mg BID x 21d then 20mg daily with food for PE. | Blood thinner dosing changes after the first 3 weeks — always take with food as instructed for lung clots. | Pulmonology | Medication Instruction | low |
622 | Levetiracetam 500mg BID; do not stop suddenly; report mood changes. | Anti-seizure medicine twice daily; taper only with clinician guidance; watch for mood side effects. | Neurology | Medication Instruction | medium |
623 | 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 | medium |
624 | Rx: Tab lisinopril 10mg daily. Humalog per SSI. Tab latanoprost 0.005% OU QHS. Adv: high fiber diet, adequate hydration Adv: fall precautions, home safety evaluation. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT. | Your medicines: (1) lisinopril 10mg once daily [blood pressure medicine that also protects kidneys]. (2) Humalog insulin before meals as directed [fast-acting insulin]. (3) latanoprost eye drops in both eyes at bedtime [glaucoma medicine]. Advice: eat plenty of fiber (fruits, vegetables, whole grains) and drink enough ... | Cardiology | Prescription | medium |
625 | Delivery Note: G?P? at 40+0 weeks. SVD. Live male infant. APGAR 8/9. EBL within expected limits. Mother stable. | Birth summary: pregnancy reached about 40+0 weeks gestation. The baby was delivered by normal vaginal delivery. The newborn is a healthy male. APGAR scores were 8/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
626 | Rx: Tab latanoprost 0.005% OU QHS. Tab ibuprofen 400mg Q6H PRN with food. Adv: wound care with daily dressing changes Adv: DASH diet, daily BP monitoring. F/U 1 month with repeat imaging. | Your medicines: (1) latanoprost eye drops in both eyes at bedtime [glaucoma medicine]. (2) ibuprofen 400mg every 6 hours as needed with food [anti-inflammatory pain reliever]. Advice: change the wound dressing once daily — clean with saline, apply ointment, cover with fresh bandage Advice: follow the DASH diet (rich in... | Ophthalmology | Prescription | medium |
627 | CT Head without contrast: No midline shift. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. Paranasal sinuses clear. | CT scan of the head results: 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. The sinuses are clear with no infection. | Neurology | Radiology Report | high |
628 | Delivery Note: G?P? at 40+0 weeks. Primary low-transverse C-section. Live female infant. APGAR 7/9. EBL within expected limits. Mother stable. | Birth summary: pregnancy reached about 40+0 weeks gestation. The baby was delivered by C-section through a low horizontal cut on the uterus. The newborn is a healthy female. APGAR scores were 7/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
629 | 60 y/o F with PMH of CKD Stage 4, CKD Stage 3, admitted for sepsis secondary to cellulitis. Blood cultures drawn. IV antibiotics started emergently. Managed per protocol with improvement. Smoking cessation counseling provided. D/C on pantoprazole 40mg AC breakfast, prednisone taper, pregabalin 75mg BID, rosuvastatin 10... | A 60-year-old woman with a history of advanced kidney disease, and moderate kidney disease was admitted for a serious blood infection from a skin infection. Blood cultures drawn. IV antibiotics started emergently. They were treated according to standard guidelines and improved. Strongly encouraged to quit smoking. Reso... | Infectious Disease | Discharge Summary | high |
630 | CBC: WBC 5.6 (N), Hgb 17.6 (H), Plt 477 (H). | Your blood count results: White blood cells are 5.6 (normal). Hemoglobin is elevated at 17.6. Platelets are 477, which is high — your blood may clot too easily. | Hematology | Lab Result | high |
631 | 38 y/o M with PMH of PPM in situ, cirrhosis, HFrEF (EF 30%), anemia, SLE, admitted for chest pain r/o ACS. Serial troponins and cardiac monitoring performed. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on furosemide 40mg BID, clopidogrel 75mg daily, warfarin 5mg daily. F/U endocrine in 1... | A 38-year-old man with a history of implanted pacemaker, liver scarring [cirrhosis], heart failure with weak pumping (30%), low blood count [anemia], and lupus was admitted for chest pain being evaluated for a possible heart attack. Serial troponins and cardiac monitoring performed. They were treated according to stand... | Cardiology | Discharge Summary | high |
632 | 91 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 91-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 |
633 | 89 y/o M with PMH of PPM in situ, RA on MTX, gout, cirrhosis, asthma, admitted for PE. CTA positive for PE. Heparin started. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on atorvastatin 80mg QHS, ciprofloxacin 500mg BID x 5 days, prednisone taper, sertraline 50mg daily. F/U INR check in 3... | A 89-year-old man with a history of implanted pacemaker, rheumatoid arthritis [on immune-suppressing medicine], gout, liver scarring [cirrhosis], and asthma 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 stand... | Pulmonology | Discharge Summary | high |
634 | 54 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 54-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 |
635 | BMP: Na 145 (N), K 3.2 (L), BUN 33, Cr 5.9 (H), Glucose 138. | Your blood chemistry results: Sodium is normal at 145. Potassium is low at 3.2 — may cause muscle weakness and heart rhythm issues. Creatinine is elevated at 5.9 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 138 (high). | Nephrology | Lab Result | high |
636 | Rx: Tab spironolactone 25mg daily. Tab acetaminophen 650mg Q6H PRN. Tab sertraline 50mg daily. Avoid NSAIDs Adv: elevate affected limb, compression stockings. F/U 6 weeks with LFTs. | Your medicines: (1) spironolactone 25mg once daily [heart-protecting water pill]. (2) Tylenol (acetaminophen) 650mg every 6 hours as needed [do not exceed 3000mg/day]. (3) sertraline 50mg once daily [antidepressant/anxiety medicine]. Do not take anti-inflammatory pain medicines like ibuprofen (Advil) or naproxen (Aleve... | Cardiology | Prescription | medium |
637 | Lipid panel: TC 198, LDL 102, HDL 46, TG 77. | Your cholesterol results: Total cholesterol is 198. LDL (bad cholesterol) is high at 102 (goal under 100). HDL (good cholesterol) is good at 46. Triglycerides are normal at 77. | Cardiology | Lab Result | high |
638 | 75 y/o F with PMH of HTN, HFpEF, A-fib, DM2, anemia, admitted for pneumonia. CXR confirmed infiltrate. Started on IV antibiotics. Managed per protocol with improvement. Wound care: daily dressing changes with wet-to-dry gauze. D/C on acetaminophen 650mg Q6H PRN, lisinopril 20mg daily. F/U nephrology in 5 days. | A 75-year-old woman with a history of high blood pressure, heart failure with stiff heart muscle, irregular heartbeat [atrial fibrillation], type 2 diabetes, and low blood count [anemia] was admitted for a lung infection. CXR confirmed infiltrate. Started on IV antibiotics. They were treated according to standard guide... | Pulmonology | Discharge Summary | high |
639 | LFTs: AST 83 (H), ALT 508 (H), ALP 244, T.Bili 1.8 (H), Albumin 2.0. | Your liver blood test results: Liver enzymes (AST 83, ALT 508) are severely elevated, indicating significant liver damage (normal is under 40). Bilirubin is mildly elevated at 1.8. Albumin is low at 2.0 (normal 3.5-5.5), suggesting the liver is struggling to make important proteins. | Gastroenterology | Lab Result | high |
640 | 82 y/o F with PMH of CKD Stage 3, COPD, s/p THR, h/o TIA, DM1, admitted for lower GI bleeding. Bright red blood per rectum. Hemoglobin dropping. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on clopidogrel 75mg daily, pantoprazole 40mg AC breakfast, ciprofloxacin 500mg BID x 5 days, ibupro... | A 82-year-old woman with a history of moderate kidney disease, chronic lung disease, prior hip replacement, history of mini-stroke, and type 1 diabetes was admitted for bleeding from the large intestine. Bright red blood per rectum. Hemoglobin dropping. They were treated according to standard guidelines and improved. B... | Gastroenterology | Discharge Summary | high |
641 | 50 y/o M with PMH of HFpEF, gout, admitted for TIA. Symptoms resolved. MRI negative for infarct. Managed per protocol with improvement. Smoking cessation counseling provided. D/C on escitalopram 10mg daily, Eliquis 5mg BID. F/U hematology in 2 weeks. | A 50-year-old man with a history of heart failure with stiff heart muscle, and gout was admitted for a mini-stroke [temporary loss of brain function]. Symptoms resolved. MRI negative for infarct. They were treated according to standard guidelines and improved. Strongly encouraged to quit smoking. Resources and support ... | Neurology | Discharge Summary | high |
642 | 39 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 39-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 |
643 | CT Head without contrast: Subarachnoid hemorrhage in bilateral sylvian fissures. Paranasal sinuses clear. Acute ischemic infarct in R MCA territory. | CT scan of the head results: There is bleeding around the brain surface, particularly in the grooves on both sides. 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. | Neurology | Radiology Report | high |
644 | Rx: Tab empagliflozin 10mg daily. Tab carvedilol 12.5mg BID. albuterol MDI 2 puffs Q4-6H PRN. Tab latanoprost 0.005% OU QHS. Adv: avoid alcohol, hepatotoxic drugs Adv: low salt diet, fluid restriction 1.5L/day. F/U 1 week with CBC, CMP. | Your medicines: (1) empagliflozin 10mg once daily [blood sugar medicine that also protects heart and kidneys]. (2) carvedilol 12.5mg twice daily [heart medicine]. (3) albuterol inhaler 2 puffs every 4-6 hours as needed [rescue inhaler for breathing]. (4) latanoprost eye drops in both eyes at bedtime [glaucoma medicine]... | Cardiology | Prescription | high |
645 | CXR PA: Moderate right pleural effusion. Compression fracture T12. No cardiomegaly. Pacemaker leads in appropriate position. | 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 heart is a normal size. The pacemaker wires are in the correct position. | Pulmonology | Radiology Report | high |
646 | 28 y/o F with PMH of anxiety, anemia, CHF, BPH, admitted for acute kidney injury. Creatinine rose sharply from baseline. Managed per protocol with improvement. Head injury precautions x 48hrs. D/C on entresto 49/51mg BID, amlodipine 10mg daily. F/U neurology in 2 weeks. | A 28-year-old woman with a history of anxiety, low blood count [anemia], heart failure, and enlarged prostate was admitted for sudden worsening of kidney function. Kidney waste products rose sharply from baseline. They were treated according to standard guidelines and improved. Watch for: worsening headache, vomiting, ... | Nephrology | Discharge Summary | high |
647 | 29 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 29-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 |
648 | CXR PA: No cardiomegaly. Osseous structures intact. Compression fracture T12. Sternotomy wires intact. ET tube 3cm above carina. | Chest X-ray results: The heart is a normal size. The bones look normal with no fractures. There is a compression fracture [collapsed bone] in the lower spine at T12. The wires from prior heart surgery are intact. The breathing tube is in good position. | Pulmonology | Radiology Report | high |
649 | 84 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 84-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 |
650 | 52 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 52-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 |
651 | 61 y/o F with PMH of HFpEF, s/p THR, DM2, admitted for sepsis secondary to UTI. Blood cultures positive. Lactate elevated. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on glipizide 5mg BID AC, lisinopril 20mg daily, empagliflozin 10mg daily. F/U PCP in 1 week. | A 61-year-old woman with a history of heart failure with stiff heart muscle, prior hip replacement, and type 2 diabetes 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 gui... | Infectious Disease | Discharge Summary | high |
652 | 73 y/o F presenting to ED with worst headache of my life, acute onset 2hrs ago. Vitals: BP 172/94, HR 78, GCS 15. CT Head: negative. LP: xanthochromic CSF, RBC 11000. CTA: 5mm ACOM aneurysm. Dx: SAH secondary to ruptured aneurysm. Nimodipine started. Neurosurgery consulted. Transfer to neuro ICU. | A 73-year-old woman came to the emergency room with the worst headache of his/her life, started suddenly 2 hours ago. Vital signs: blood pressure elevated, heart rate normal, fully alert. CT scan did not show bleeding. Spinal tap showed blood in spinal fluid confirming brain bleed. Blood vessel scan found a 5mm bulge [... | Emergency Medicine | Clinical Note | high |
653 | 37 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 37-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 |
654 | HbA1c: 12.8% (H). FBS: 190 mg/dL (H). | Your diabetes blood test results: HbA1c is 12.8%, which is very high, meaning blood sugar has been dangerously uncontrolled (target is under 7%). Fasting blood sugar was 190, which is high (normal is 70-100). Urgent medication adjustment needed. Very high risk of diabetes complications at this level. | Endocrinology | Lab Result | high |
655 | 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 | high |
656 | 80 y/o M with PMH of DM2, h/o CVA, HFpEF, osteoporosis, admitted for lower GI bleeding. Bright red blood per rectum. Hemoglobin dropping. Managed per protocol with improvement. Low potassium diet. D/C on atorvastatin 40mg QHS, Spiriva 18mcg daily, amlodipine 5mg daily, Eliquis 5mg BID. F/U orthopedics in 6 weeks with X... | A 80-year-old man with a history of type 2 diabetes, history of stroke, heart failure with stiff heart muscle, and weak bones [osteoporosis] was admitted for bleeding from the large intestine. Bright red blood per rectum. Hemoglobin dropping. They were treated according to standard guidelines and improved. Avoid high-p... | Gastroenterology | Discharge Summary | high |
657 | Doxycycline 100mg BID x 14 days with water; stay upright 30 min; avoid sun. | Take this antibiotic twice daily for 14 days with plenty of water, stay upright after doses, and use sun protection. | Infectious Disease | Medication Instruction | medium |
658 | CXR PA: Patchy bilateral infiltrates. Hyperinflated lungs consistent with COPD. ET tube 3cm above carina. Left lower lobe consolidation. Mild cardiomegaly. | Chest X-ray results: There are scattered cloudy patches in both lungs suggesting infection or inflammation. The lungs appear over-inflated, which is typical of chronic lung disease [COPD/emphysema]. The breathing tube is in good position. There is an area in the lower left lung that appears infected. The heart is sligh... | Pulmonology | Radiology Report | high |
659 | Rx: Tab gabapentin 300mg TID. Tab Augmentin 875/125 BID x 7 days. Humalog per SSI. Tab Dulcolax 10mg QHS PRN. Tab atorvastatin 80mg QHS. Adv: weight bearing exercise, calcium/vit D supplementation Avoid NSAIDs. F/U 1 month with repeat imaging. | Your medicines: (1) gabapentin 300mg three times daily [nerve pain medicine — may cause drowsiness]. (2) Augmentin 875mg twice daily for 7 days [antibiotic]. (3) Humalog insulin before meals as directed [fast-acting insulin]. (4) Dulcolax 10mg at bedtime as needed [for constipation]. (5) atorvastatin 80mg at bedtime [h... | Pediatrics | Prescription | high |
660 | 47 y/o F presenting to ED with acute onset SOB, unable to speak in full sentences. Vitals: BP 168/92, HR 118, RR 28, O2 85% on RA. CXR: bilateral pleural effusions, pulmonary edema. BNP 2400. Dx: Acute decompensated CHF. IV furosemide 80mg, BiPAP, nitroglycerin drip. Admit CCU. | A 47-year-old woman came to the emergency room with sudden severe difficulty breathing, unable to finish sentences. Vital signs: blood pressure high, heart rate very fast, breathing very rapid, oxygen dangerously low at 85%. Chest X-ray showed fluid in both lungs. Heart failure blood test very high. Diagnosis: severe h... | Emergency Medicine | Clinical Note | high |
661 | 73 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 73-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 |
662 | 60 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 60-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 |
663 | 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 |
664 | CT Head without contrast: Subarachnoid hemorrhage in bilateral sylvian fissures. Mild generalized cerebral atrophy appropriate for age. Chronic lacunar infarcts in bilateral basal ganglia. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. | CT scan of the head results: There is bleeding around the brain surface, particularly in the grooves on both sides. There is mild brain shrinkage, which is normal for your age. There are signs of small old strokes in the deep parts of the brain. There are aging-related changes in the brain's white matter from reduced b... | Neurology | Radiology Report | high |
665 | Rx: Tab timolol 0.5% OU BID. Tab Dulcolax 10mg QHS PRN. Tab ciprofloxacin 500mg BID x 5 days. Tab acetaminophen 650mg Q6H PRN. Adv: high fiber diet, adequate hydration Adv: SMBG BID, diabetic diet. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT. | Your medicines: (1) timolol eye drops in both eyes twice daily [lowers eye pressure for glaucoma]. (2) Dulcolax 10mg at bedtime as needed [for constipation]. (3) ciprofloxacin 500mg twice daily for 5 days [antibiotic — avoid dairy within 2 hours]. (4) Tylenol (acetaminophen) 650mg every 6 hours as needed [do not exceed... | General | Prescription | high |
666 | Enoxaparin 40mg SC daily until walking regularly. | Injection helps prevent clots until you are walking normally. | General | Medication Instruction | high |
667 | Procedure: ERCP with sphincterotomy. Pt 34 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 34-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 |
668 | CBC: WBC 5.6 (N), Hgb 12.8 (N), Plt 430 (H). | Your blood count results: White blood cells are 5.6 (normal). Hemoglobin is normal at 12.8. Platelets are 430, which is high — your blood may clot too easily. | Hematology | Lab Result | high |
669 | 67 y/o M with PMH of s/p THR, CKD Stage 4, GERD, h/o TIA, admitted for DVT. Ultrasound confirmed DVT. Anticoagulation started. Managed per protocol with improvement. Low potassium diet. D/C on metformin 1000mg BID, sertraline 50mg daily, lisinopril 10mg daily, amlodipine 5mg daily. F/U PCP in 1 week. | A 67-year-old man with a history of prior hip replacement, advanced kidney disease, acid reflux, and history of mini-stroke was admitted for a blood clot in the leg [deep vein thrombosis]. Ultrasound confirmed DVT. Anticoagulation started. They were treated according to standard guidelines and improved. Avoid high-pota... | Hematology | Discharge Summary | high |
670 | Rx: Tab tramadol 50mg Q6H PRN pain. Tab ondansetron 4mg Q8H PRN N/V. Tab azithromycin 500mg day 1 then 250mg x 4 days. Tab metformin 500mg BID. Tab empagliflozin 10mg daily. Adv: smoking cessation, pulmonary rehab Avoid NSAIDs. F/U 1 week with CBC, CMP. | Your medicines: (1) tramadol 50mg every 6 hours as needed for pain [may cause drowsiness — max 4/day]. (2) ondansetron (Zofran) 4mg every 8 hours as needed [anti-nausea medicine]. (3) azithromycin: 500mg on day 1, then 250mg for the next 4 days [antibiotic]. (4) metformin 500mg twice daily with meals [blood sugar medic... | Endocrinology | Prescription | high |
671 | 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 |
672 | Escitalopram 10mg AM; effect builds over weeks; avoid abrupt alcohol use. | Antidepressant taken in the morning; benefits increase over several weeks; limit alcohol. | Psychiatry | Medication Instruction | medium |
673 | Delivery Note: G?P? at 40+0 weeks. Primary low-transverse C-section. Live female infant. APGAR 7/9. EBL within expected limits. Mother stable. | Birth summary: pregnancy reached about 40+0 weeks gestation. The baby was delivered by C-section through a low horizontal cut on the uterus. The newborn is a healthy female. APGAR scores were 7/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
674 | Rx: Tab furosemide 40mg daily. Tab amlodipine 10mg daily. Tab warfarin 5mg daily. Adv: smoking cessation, pulmonary rehab. F/U 2 weeks. | Your medicines: (1) furosemide (Lasix) 40mg once daily [water pill to remove extra fluid]. (2) amlodipine 10mg once daily [blood pressure medicine]. (3) warfarin 5mg once daily [blood thinner — requires regular INR blood tests]. Advice: stop smoking (ask about nicotine patches or gum) and attend lung rehabilitation pro... | Cardiology | Prescription | medium |
675 | Rx: Tab acetaminophen 650mg Q6H PRN. Tab ASA 81mg daily. Tab montelukast 10mg QHS. Adv: SMBG BID, diabetic diet Adv: smoking cessation, pulmonary rehab. 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) baby aspirin 81mg once daily [prevents blood clots]. (3) montelukast 10mg at bedtime [asthma/allergy medicine]. Advice: check your blood sugar twice daily and follow a diabetes-friendly diet Advice: stop smoking (a... | Cardiology | Prescription | medium |
676 | CT Head without contrast: Acute ischemic infarct in R MCA territory. Paranasal sinuses clear. Mild generalized cerebral atrophy appropriate for age. | CT scan of the head results: There is a new stroke affecting the right side of the brain, in the area supplied by the middle cerebral artery. The sinuses are clear with no infection. There is mild brain shrinkage, which is normal for your age. | Neurology | Radiology Report | high |
677 | Procedure: R TKA. Pt 38 y/o F. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes total knee replacement on the right for a 38-year-old woman. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | Orthopedics | Procedure Note | high |
678 | 73 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 73-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 |
679 | Thyroid panel: TSH 2.05 (N), Free T4 1.0. | Your thyroid test results: TSH is normal at 2.05. Free T4 is normal — your thyroid function is balanced. | Endocrinology | Lab Result | medium |
680 | Rx: Tab metformin 500mg BID. Tab Dulcolax 10mg QHS PRN. Tab furosemide 40mg daily. Tab ibuprofen 400mg Q6H PRN with food. Adv: avoid alcohol, hepatotoxic drugs Adv: DASH diet, daily BP monitoring. F/U INR in 3 days. | Your medicines: (1) metformin 500mg twice daily with meals [blood sugar medicine]. (2) Dulcolax 10mg at bedtime as needed [for constipation]. (3) furosemide (Lasix) 40mg once daily [water pill to remove extra fluid]. (4) ibuprofen 400mg every 6 hours as needed with food [anti-inflammatory pain reliever]. Advice: do not... | General | Prescription | high |
681 | US Abdomen: Right kidney 10.5cm, no hydronephrosis. Pancreas unremarkable. Simple renal cysts bilaterally. | Abdominal ultrasound results: Right kidney is normal size with no blockage. The pancreas looks normal. Both kidneys have harmless fluid-filled cysts. | Gastroenterology | Radiology Report | high |
682 | 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 | low |
683 | 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 |
684 | 81 y/o F with PMH of Parkinson's disease, HTN, admitted for chest pain r/o ACS. Serial troponins and cardiac monitoring performed. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on warfarin 5mg daily, carvedilol 12.5mg BID, Eliquis 5mg BID, amlodipine 10mg daily, metoprolol 25mg ... | A 81-year-old woman with a history of Parkinson's disease, and high blood pressure 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. Write down your blood sugar readings in a log bo... | Cardiology | Discharge Summary | high |
685 | 41 y/o M with PMH of cirrhosis, PPM in situ, HLD, admitted for appendicitis. CT confirmed. Taken to OR for laparoscopic appendectomy. Managed per protocol with improvement. Strict I&O, daily weights. D/C on sertraline 50mg daily, hydroxychloroquine 200mg BID, prednisone taper, Spiriva 18mcg daily. F/U oncology in 1 wee... | A 41-year-old man with a history of liver scarring [cirrhosis], implanted pacemaker, and high cholesterol was admitted for inflammation of the appendix. CT confirmed. Taken to OR for laparoscopic appendectomy. They were treated according to standard guidelines and improved. Track how much you drink and urinate. Weigh y... | General Surgery | Discharge Summary | high |
686 | CXR PA: ET tube 3cm above carina. Increased interstitial markings suggesting pulmonary edema. Pacemaker leads in appropriate position. Left lower lobe consolidation. No pneumothorax. | Chest X-ray results: The breathing tube is in good position. There are signs of extra fluid in the lung tissue, suggesting the heart may not be pumping efficiently [pulmonary edema]. The pacemaker wires are in the correct position. There is an area in the lower left lung that appears infected. There is no collapsed lun... | Pulmonology | Radiology Report | high |
687 | 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 |
688 | Procedure: TURP for BPH. Pt 89 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 89-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 |
689 | Delivery Note: G?P? at 39+1 weeks. Primary low-transverse C-section. 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 C-section through a low horizontal cut on the uterus. The newborn is a healthy female. APGAR scores were 9/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
690 | Rx: Tab ondansetron 4mg Q8H PRN N/V. Spiriva 18mcg daily. Tab hydroxychloroquine 200mg BID. Adv: DASH diet, daily BP monitoring Adv: smoking cessation, pulmonary rehab. F/U 1 week with wound check. | Your medicines: (1) ondansetron (Zofran) 4mg every 8 hours as needed [anti-nausea medicine]. (2) Spiriva inhaler once daily [long-acting lung medicine]. (3) hydroxychloroquine 200mg twice daily [immune-modulating medicine — eye exams needed]. Advice: follow the DASH diet (rich in fruits, vegetables, lean protein, low i... | Pulmonology | Prescription | medium |
691 | Rx: Tab timolol 0.5% OU BID. Tab atorvastatin 80mg QHS. Tab entresto 49/51mg BID. Tab empagliflozin 10mg daily. Avoid NSAIDs Adv: high fiber diet, adequate hydration. F/U 2 weeks with INR. | Your medicines: (1) timolol eye drops in both eyes twice daily [lowers eye pressure for glaucoma]. (2) atorvastatin 80mg at bedtime [high-dose cholesterol medicine]. (3) Entresto 49/51mg twice daily [heart failure medicine]. (4) empagliflozin 10mg once daily [blood sugar medicine that also protects heart and kidneys]. ... | Cardiology | Prescription | high |
692 | 84 y/o F with PMH of HFrEF (EF 30%), ICD in situ, h/o TIA, depression, HLD, admitted for PE. CTA positive for PE. Heparin started. Managed per protocol with improvement. Strict NPO after midnight before procedure. D/C on omeprazole 20mg AC breakfast, prednisone taper. F/U neurology in 2 weeks. | A 84-year-old woman with a history of heart failure with weak pumping (30%), implanted heart defibrillator, history of mini-stroke, depression, and high cholesterol 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 ... | Pulmonology | Discharge Summary | high |
693 | MRI Lumbar Spine: L4-L5 disc herniation with moderate bilateral foraminal stenosis. Facet joint hypertrophy at L4-L5. | MRI of the lower back results: At the L4-L5 level, a disc has pushed outward [herniated] and is narrowing the nerve tunnels on both sides. The small joints in the spine at L4-L5 are enlarged from arthritis. | Orthopedics | Radiology Report | high |
694 | Procedure: Laparoscopic cholecystectomy. Pt 42 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 42-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 |
695 | BMP: Na 128 (L), K 4.6 (N), BUN 26, Cr 0.6 (N), Glucose 251. | Your blood chemistry results: Sodium is low at 128 (normal 136-145), meaning too much water in your body. Potassium is normal at 4.6. Creatinine is normal at 0.6. Blood sugar is 251 (high). | Nephrology | Lab Result | high |
696 | CBC: WBC 10.2 (N), Hgb 12.4 (N), Plt 214 (N). | Your blood count results: White blood cells are 10.2 (normal). Hemoglobin is normal at 12.4. Platelets are 214, which is normal. | Hematology | Lab Result | medium |
697 | Rx: Tab atorvastatin 40mg QHS. Tab glipizide 5mg BID AC. Do not stop abruptly, taper as directed Adv: DASH diet, daily BP monitoring. F/U 1 month with repeat imaging. | Your medicines: (1) atorvastatin 40mg at bedtime [cholesterol medicine]. (2) glipizide 5mg twice daily before meals [helps release insulin]. Do not suddenly stop this medicine — your doctor will gradually reduce the dose if needed Advice: follow the DASH diet (rich in fruits, vegetables, lean protein, low in salt) and ... | Cardiology | Prescription | medium |
698 | BMP: Na 139 (N), K 2.9 (L), BUN 13, Cr 0.9 (N), Glucose 86. | Your blood chemistry results: Sodium is normal at 139. Potassium is low at 2.9 — may cause muscle weakness and heart rhythm issues. Creatinine is normal at 0.9. Blood sugar is 86 (normal). | Nephrology | Lab Result | high |
699 | Rx: Tab hydroxychloroquine 200mg BID. Tab furosemide 40mg BID. Tab entresto 49/51mg BID. Adv: low potassium diet Adv: weight bearing exercise, calcium/vit D supplementation. F/U 1 month with repeat imaging. | Your medicines: (1) hydroxychloroquine 200mg twice daily [immune-modulating medicine — eye exams needed]. (2) furosemide (Lasix) 40mg twice daily [water pill]. (3) Entresto 49/51mg twice daily [heart failure medicine]. Advice: avoid high-potassium foods like bananas, oranges, potatoes, and tomatoes Advice: do weight-be... | Cardiology | Prescription | medium |
700 | Enoxaparin 40mg SC daily until walking regularly. | Injection helps prevent clots until you are walking normally. | General | Medication Instruction | medium |
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