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901 | Procedure: R TKA. Pt 80 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 80-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 |
902 | 42 y/o M presenting to ED with acute onset SOB, unable to speak in full sentences. Vitals: BP 168/92, HR 118, RR 28, O2 85% on RA. CXR: bilateral pleural effusions, pulmonary edema. BNP 2400. Dx: Acute decompensated CHF. IV furosemide 80mg, BiPAP, nitroglycerin drip. Admit CCU. | A 42-year-old man came to the emergency room with sudden severe difficulty breathing, unable to finish sentences. Vital signs: blood pressure high, heart rate very fast, breathing very rapid, oxygen dangerously low at 85%. Chest X-ray showed fluid in both lungs. Heart failure blood test very high. Diagnosis: severe hea... | Emergency Medicine | Clinical Note | high |
903 | CXR PA: Port-a-cath in appropriate position. Bilateral hilar lymphadenopathy. Mild cardiomegaly. Pacemaker leads in appropriate position. | Chest X-ray results: The implanted medication port is in the correct position. There are enlarged lymph nodes at the root of both lungs, which needs further evaluation. The heart is slightly larger than normal. The pacemaker wires are in the correct position. | Pulmonology | Radiology Report | high |
904 | 35 y/o F with PMH of CKD Stage 4, BPH, ESRD on HD, admitted for DVT. Ultrasound confirmed DVT. Anticoagulation started. Managed per protocol with improvement. Daily weights, 1.5L fluid restriction, low sodium diet. D/C on Augmentin 875/125 BID x 7 days, entresto 49/51mg BID. F/U INR check in 3 days. | A 35-year-old woman with a history of advanced kidney disease, enlarged prostate, and kidney failure requiring dialysis 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. Weigh yourself ever... | Hematology | Discharge Summary | high |
905 | BMP: Na 130 (L), K 5.8 (H), BUN 32, Cr 1.3 (H), Glucose 365. | Your blood chemistry results: Sodium is low at 130 (normal 136-145), meaning too much water in your body. Potassium is dangerously high at 5.8 (normal 3.5-5.0) — this can affect your heart and needs immediate treatment. Creatinine is mildly elevated at 1.3. Blood sugar is 365 (high). | Nephrology | Lab Result | high |
906 | BMP: Na 122 (L), K 4.6 (N), BUN 83, Cr 3.8 (H), Glucose 268. | Your blood chemistry results: Sodium is low at 122 (normal 136-145), meaning too much water in your body. Potassium is normal at 4.6. Creatinine is elevated at 3.8 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 268 (high). | Nephrology | Lab Result | high |
907 | Procedure: R TKA. Pt 30 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 30-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 |
908 | Rx: Tab azithromycin 500mg day 1 then 250mg x 4 days. Tab sertraline 50mg daily. Tab montelukast 10mg QHS. Adv: SMBG BID, diabetic diet. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT. | Your medicines: (1) azithromycin: 500mg on day 1, then 250mg for the next 4 days [antibiotic]. (2) sertraline 50mg once daily [antidepressant/anxiety medicine]. (3) montelukast 10mg at bedtime [asthma/allergy medicine]. Advice: check your blood sugar twice daily and follow a diabetes-friendly diet. Come back in 2 weeks... | Pulmonology | Prescription | medium |
909 | 32 y/o F with PMH of HFrEF (EF 30%), PPM in situ, h/o CVA, admitted for pyelonephritis. UA showed infection. Flank pain and fever. IV antibiotics started. Managed per protocol with improvement. Diabetic diet, SMBG BID. D/C on metformin 1000mg BID, ASA 81mg daily, sertraline 50mg daily, levothyroxine 75mcg daily on empt... | A 32-year-old woman with a history of heart failure with weak pumping (30%), implanted pacemaker, and history of stroke 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. Follow a dia... | Urology | Discharge Summary | high |
910 | MRI Lumbar Spine: L5-S1 disc desiccation with mild bulge. No compression fracture. Conus medullaris at L1, normal. Multilevel degenerative disc disease. | 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. Multiple discs in the spine are showing wear and aging. | Orthopedics | Radiology Report | high |
911 | Rx: Tab clopidogrel 75mg daily. Tab metoprolol 25mg BID. Tab spironolactone 25mg daily. Tab atorvastatin 40mg QHS. Tab omeprazole 20mg AC breakfast. Adv: wound care with daily dressing changes Adv: elevate affected limb, compression stockings. F/U INR in 3 days. | Your medicines: (1) Plavix (clopidogrel) 75mg once daily [blood thinner]. (2) metoprolol 25mg twice daily [slows heart rate and lowers blood pressure]. (3) spironolactone 25mg once daily [heart-protecting water pill]. (4) atorvastatin 40mg at bedtime [cholesterol medicine]. (5) omeprazole 20mg before breakfast [acid-re... | Cardiology | Prescription | high |
912 | 91 y/o M with PMH of hypothyroidism, OA, HLD, GERD, COPD, admitted for cholecystitis. US showed gallbladder wall thickening and stones. Surgery consulted. Managed per protocol with improvement. Diabetic diet, SMBG BID. D/C on ibuprofen 400mg Q6H PRN with food, levothyroxine 75mcg daily on empty stomach, sertraline 50mg... | A 91-year-old man with a history of underactive thyroid, arthritis [osteoarthritis], high cholesterol, acid reflux, and chronic lung disease was admitted for gallbladder infection/inflammation. US showed gallbladder wall thickening and stones. Surgery consulted. They were treated according to standard guidelines and im... | General Surgery | Discharge Summary | high |
913 | Rx: Tab calcium + vitamin D 600/400 daily. Tab ferrous sulfate 325mg BID. Tab Augmentin 875/125 BID x 7 days. Tab latanoprost 0.005% OU QHS. Adv: weight bearing exercise, calcium/vit D supplementation Adv: fall precautions, home safety evaluation. F/U PCP in 1 week for BP recheck. | Your medicines: (1) calcium plus vitamin D once daily [bone strengthening]. (2) iron supplement 325mg twice daily [for low blood count — take with vitamin C]. (3) Augmentin 875mg twice daily for 7 days [antibiotic]. (4) latanoprost eye drops in both eyes at bedtime [glaucoma medicine]. Advice: do weight-bearing exercis... | General | Prescription | high |
914 | Rx: Tab pantoprazole 40mg AC breakfast. Tab potassium chloride 20mEq daily. Adv: weight bearing exercise, calcium/vit D supplementation Adv: fall precautions, home safety evaluation. F/U PCP in 1 week for BP recheck. | Your medicines: (1) pantoprazole 40mg before breakfast [acid-reducing medicine]. (2) potassium supplement 20mEq once daily [replaces potassium lost from water pills]. Advice: do weight-bearing exercises (walking, light weights) and take calcium and vitamin D for bone strength Advice: take steps to prevent falls — remov... | Gastroenterology | Prescription | medium |
915 | 53 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 53-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 |
916 | CT Head without contrast: No midline shift. Paranasal sinuses clear. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. Subarachnoid hemorrhage in bilateral sylvian fissures. | CT scan of the head results: The brain is centered normally. The sinuses are clear with no infection. There are aging-related changes in the brain's white matter from reduced blood flow to small vessels over time. There is bleeding around the brain surface, particularly in the grooves on both sides. | Neurology | Radiology Report | high |
917 | 56 y/o M presenting to ED with RLQ pain x 12hrs, anorexia, low-grade fever. Vitals: BP 128/76, HR 96, T 100.8F. CT abdomen: 9mm dilated appendix with periappendiceal fat stranding, no perforation. Dx: Acute uncomplicated appendicitis. NPO, IV Zosyn. Surgery consulted for laparoscopic appendectomy. Admit surgery. | A 56-year-old man came to the emergency room with pain in the lower right belly for 12 hours, loss of appetite, and mild fever. Vital signs: blood pressure normal, heart rate slightly fast, mild fever. CT scan showed the appendix is swollen (9mm, normal <6mm) with inflammation around it but no rupture. Diagnosis: appen... | Emergency Medicine | Clinical Note | high |
918 | Levetiracetam 500mg BID; do not stop suddenly; report mood changes. | Anti-seizure medicine twice daily; taper only with clinician guidance; watch for mood side effects. | Neurology | Medication Instruction | low |
919 | 44 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 44-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 |
920 | 23 y/o M with PMH of CKD Stage 4, h/o TIA, admitted for cellulitis L lower extremity. Area was red, warm, and swollen. Marked with pen to track spread. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on atorvastatin 80mg QHS, amlodipine 5mg daily, tramadol 50mg Q6H PRN pain, timol... | A 23-year-old man with a history of advanced kidney disease, and history of mini-stroke was admitted for a skin infection in the left leg. Area was red, warm, and swollen. Marked with pen to track spread. They were treated according to standard guidelines and improved. Write down your blood sugar readings in a log book... | Infectious Disease | Discharge Summary | high |
921 | Delivery Note: G?P? at 40+0 weeks. Primary low-transverse C-section. 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 C-section through a low horizontal cut on the uterus. The newborn is a healthy male. APGAR scores were 8/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
922 | 50 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 50-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 |
923 | 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 |
924 | 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 |
925 | 84 y/o M with PMH of OA, CHF, DM1, admitted for fall with hip fracture. X-ray confirmed femoral neck fracture. Orthopedics consulted. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on montelukast 10mg QHS, pantoprazole 40mg AC breakfast, potassium chloride 20mEq daily. F/U oncology in 1 wee... | A 84-year-old man with a history of arthritis [osteoarthritis], heart failure, and type 1 diabetes was admitted for broken hip after a fall. X-ray confirmed femoral neck fracture. Orthopedics consulted. They were treated according to standard guidelines and improved. Be careful to prevent falls. Physical therapy and oc... | Orthopedics | Discharge Summary | high |
926 | 38 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 38-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 |
927 | Procedure: TURP for BPH. Pt 23 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 23-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 |
928 | LFTs: AST 479 (H), ALT 596 (H), ALP 115, T.Bili 6.7 (H), Albumin 3.1. | Your liver blood test results: Liver enzymes (AST 479, ALT 596) are severely elevated, indicating significant liver damage (normal is under 40). Bilirubin is high at 6.7 (normal under 1.2) — may cause yellowing of skin and eyes [jaundice]. Albumin is low at 3.1 (normal 3.5-5.5), suggesting the liver is struggling to ma... | Gastroenterology | Lab Result | high |
929 | 23 y/o F with PMH of HTN, anemia, hypothyroidism, PAD, admitted for acute kidney injury. Creatinine rose sharply from baseline. Managed per protocol with improvement. Compression stockings when ambulating. D/C on acetaminophen 650mg Q6H PRN, latanoprost 0.005% OU QHS. F/U pulmonology in 2 weeks. | A 23-year-old woman with a history of high blood pressure, low blood count [anemia], underactive thyroid, and poor blood flow in the legs [peripheral artery disease] was admitted for sudden worsening of kidney function. Kidney waste products rose sharply from baseline. They were treated according to standard guidelines... | Nephrology | Discharge Summary | high |
930 | LFTs: AST 398 (H), ALT 296 (H), ALP 63, T.Bili 0.4 (N), Albumin 4.0. | Your liver blood test results: Liver enzymes (AST 398, ALT 296) are severely elevated, indicating significant liver damage (normal is under 40). Bilirubin is normal at 0.4. Albumin is normal at 4.0. | Gastroenterology | Lab Result | high |
931 | 28 y/o M with PMH of s/p THR, DVT/PE on warfarin, CHF, admitted for acute kidney injury. Creatinine rose sharply from baseline. Managed per protocol with improvement. BRAT diet x 48hrs, advance as tolerated. D/C on Spiriva 18mcg daily, ondansetron 4mg Q8H PRN N/V. F/U orthopedics in 6 weeks with X-ray. | A 28-year-old man with a history of prior hip replacement, blood clots [on blood thinner warfarin], and heart failure was admitted for sudden worsening of kidney function. Kidney waste products rose sharply from baseline. They were treated according to standard guidelines and improved. Eat bland food for 48 hours (bana... | Nephrology | Discharge Summary | high |
932 | 27 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 27-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 |
933 | Rx: Tab furosemide 40mg daily. Tab levothyroxine 75mcg daily on empty stomach. Tab carvedilol 12.5mg BID. Adv: SMBG BID, diabetic diet Adv: avoid alcohol, hepatotoxic drugs. F/U 1 week with wound check. | Your medicines: (1) furosemide (Lasix) 40mg once daily [water pill to remove extra fluid]. (2) levothyroxine 75mcg on empty stomach 30 min before breakfast [thyroid medicine]. (3) carvedilol 12.5mg twice daily [heart medicine]. Advice: check your blood sugar twice daily and follow a diabetes-friendly diet Advice: do no... | Cardiology | Prescription | medium |
934 | PATH: Breast: IDC, Nottingham grade 2, ER/PR positive, HER2 negative, margins negative. | Pathology results in plain language: Breast biopsy shows invasive ductal carcinoma, moderately aggressive. Hormone receptors positive (often treatable with hormone therapy). HER2 negative. Edges of tissue clear of cancer. | Oncology | Pathology Report | high |
935 | 75 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 75-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 |
936 | Rx: prednisone taper. Tab montelukast 10mg QHS. Tab lisinopril 10mg daily. Tab clopidogrel 75mg daily. Tab latanoprost 0.005% OU QHS. Adv: elevate affected limb, compression stockings Adv: low salt diet, fluid restriction 1.5L/day. F/U 2 weeks with INR. | Your medicines: (1) prednisone steroid — dose gradually decreases as directed [do not stop suddenly]. (2) montelukast 10mg at bedtime [asthma/allergy medicine]. (3) lisinopril 10mg once daily [blood pressure medicine that also protects kidneys]. (4) Plavix (clopidogrel) 75mg once daily [blood thinner]. (5) latanoprost ... | Cardiology | Prescription | high |
937 | Rx: Tab azithromycin 500mg day 1 then 250mg x 4 days. Tab clopidogrel 75mg daily. Tab acetaminophen 650mg Q6H PRN. Adv: low salt low sugar diet, regular exercise Adv: fall precautions, home safety evaluation. F/U 2 weeks. | Your medicines: (1) azithromycin: 500mg on day 1, then 250mg for the next 4 days [antibiotic]. (2) Plavix (clopidogrel) 75mg once daily [blood thinner]. (3) Tylenol (acetaminophen) 650mg every 6 hours as needed [do not exceed 3000mg/day]. Advice: eat less salt and sugar, and exercise at least 30 minutes most days Advic... | Cardiology | Prescription | medium |
938 | Delivery Note: G?P? at 39+1 weeks. Primary low-transverse C-section. Live female infant. APGAR 7/9. 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 7/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
939 | LFTs: AST 430 (H), ALT 394 (H), ALP 152, T.Bili 4.8 (H), Albumin 3.5. | Your liver blood test results: Liver enzymes (AST 430, ALT 394) are severely elevated, indicating significant liver damage (normal is under 40). Bilirubin is high at 4.8 (normal under 1.2) — may cause yellowing of skin and eyes [jaundice]. Albumin is normal at 3.5. | Gastroenterology | Lab Result | high |
940 | 29 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 29-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 |
941 | CXR PA: No pneumothorax. Right lower lobe consolidation. Right middle lobe atelectasis. Compression fracture T12. | Chest X-ray results: There is no collapsed lung. 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. There is a compression fracture [collapsed bone] in the lower spine at T12. | Pulmonology | Radiology Report | high |
942 | 62 y/o F with PMH of ESRD on HD, HLD, BPH, gout, GERD, admitted for acute pancreatitis. Lipase markedly elevated. CT showed peripancreatic inflammation. Managed per protocol with improvement. BRAT diet x 48hrs, advance as tolerated. D/C on amlodipine 10mg daily, losartan 50mg daily. F/U oncology in 1 week. | A 62-year-old woman with a history of kidney failure requiring dialysis, high cholesterol, enlarged prostate, gout, and acid reflux was admitted for severe inflammation of the pancreas. A pancreas enzyme was very high. CT scan showed peripancreatic inflammation. They were treated according to standard guidelines and im... | Gastroenterology | Discharge Summary | high |
943 | CXR PA: Right middle lobe atelectasis. Compression fracture T12. Osseous structures intact. No cardiomegaly. | Chest X-ray results: Part of the right lung has partially collapsed [atelectasis], possibly from mucus plugging. There is a compression fracture [collapsed bone] in the lower spine at T12. The bones look normal with no fractures. The heart is a normal size. | Pulmonology | Radiology Report | high |
944 | 63 y/o M presenting to ED with RLQ pain x 12hrs, anorexia, low-grade fever. Vitals: BP 128/76, HR 96, T 100.8F. CT abdomen: 9mm dilated appendix with periappendiceal fat stranding, no perforation. Dx: Acute uncomplicated appendicitis. NPO, IV Zosyn. Surgery consulted for laparoscopic appendectomy. Admit surgery. | A 63-year-old man came to the emergency room with pain in the lower right belly for 12 hours, loss of appetite, and mild fever. Vital signs: blood pressure normal, heart rate slightly fast, mild fever. CT scan showed the appendix is swollen (9mm, normal <6mm) with inflammation around it but no rupture. Diagnosis: appen... | Emergency Medicine | Clinical Note | high |
945 | 53 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 53-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 |
946 | Rx: Tab glipizide 5mg BID AC. Tab latanoprost 0.005% OU QHS. Adv: wound care with daily dressing changes. F/U INR in 3 days. | Your medicines: (1) glipizide 5mg twice daily before meals [helps release insulin]. (2) latanoprost eye drops in both eyes at bedtime [glaucoma medicine]. Advice: change the wound dressing once daily — clean with saline, apply ointment, cover with fresh bandage. Come back in 3 days for a blood thinner level check [INR]... | Endocrinology | Prescription | medium |
947 | 82 y/o M with PMH of HFpEF, hypothyroidism, s/p TKR, admitted for upper GI bleeding. Hematemesis noted. EGD showed bleeding ulcer. Managed per protocol with improvement. Strict NPO after midnight before procedure. D/C on montelukast 10mg QHS, ASA 81mg daily, entresto 49/51mg BID, metformin 1000mg BID, pregabalin 75mg B... | A 82-year-old man with a history of heart failure with stiff heart muscle, underactive thyroid, and prior knee replacement was admitted for bleeding from the stomach or food pipe. Hematemesis noted. EGD showed bleeding ulcer. They were treated according to standard guidelines and improved. Do not eat or drink anything ... | Gastroenterology | Discharge Summary | high |
948 | CT Head without contrast: Subarachnoid hemorrhage in bilateral sylvian fissures. 4cm right subdural hematoma with 5mm midline shift. No acute intracranial hemorrhage. Chronic lacunar infarcts in bilateral basal ganglia. No mass effect. | CT scan of the head results: There is bleeding around the brain surface, particularly in the grooves on both sides. There is a significant blood collection (4cm) on the right side between the brain and skull, pushing the brain 5mm to the left — this is serious. There is no bleeding in the brain. There are signs of smal... | Neurology | Radiology Report | high |
949 | 69 y/o M presenting to ED with severe allergic reaction after eating shellfish, diffuse urticaria, lip/tongue swelling, wheezing. Vitals: BP 82/50, HR 132, RR 28, O2 90%. Clinical diagnosis of anaphylaxis based on exam. Dx: Anaphylaxis. Epinephrine 0.3mg IM x 2 doses. IV NS 2L bolus. IV methylprednisolone 125mg. IV dip... | A 69-year-old man came to the emergency room with severe allergic reaction after eating shellfish — hives all over body, lips and tongue swelling, wheezing. Vital signs: blood pressure dangerously low (shock), heart rate very fast, breathing rapid, oxygen low. Examination and vital signs support a severe systemic aller... | Emergency Medicine | Clinical Note | high |
950 | 73 y/o M presenting to ED with RLQ pain x 12hrs, anorexia, low-grade fever. Vitals: BP 128/76, HR 96, T 100.8F. CT abdomen: 9mm dilated appendix with periappendiceal fat stranding, no perforation. Dx: Acute uncomplicated appendicitis. NPO, IV Zosyn. Surgery consulted for laparoscopic appendectomy. Admit surgery. | A 73-year-old man came to the emergency room with pain in the lower right belly for 12 hours, loss of appetite, and mild fever. Vital signs: blood pressure normal, heart rate slightly fast, mild fever. CT scan showed the appendix is swollen (9mm, normal <6mm) with inflammation around it but no rupture. Diagnosis: appen... | Emergency Medicine | Clinical Note | high |
951 | US Abdomen: Spleen 11cm, normal. CBD 5mm, not dilated. Pancreas unremarkable. | Abdominal ultrasound results: The spleen is a normal size. The bile duct is normal size [not blocked]. The pancreas looks normal. | Gastroenterology | Radiology Report | high |
952 | Rx: Tab ferrous sulfate 325mg BID. Tab lisinopril 10mg daily. Humalog per SSI. Adv: wound care with daily dressing changes. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT. | Your medicines: (1) iron supplement 325mg twice daily [for low blood count — take with vitamin C]. (2) lisinopril 10mg once daily [blood pressure medicine that also protects kidneys]. (3) Humalog insulin before meals as directed [fast-acting insulin]. Advice: change the wound dressing once daily — clean with saline, ap... | Cardiology | Prescription | medium |
953 | Rx: Tab acetaminophen 650mg Q6H PRN. Tab lisinopril 20mg daily. Tab Eliquis 5mg BID. Tab amlodipine 10mg daily. Tab losartan 50mg daily. Adv: wound care with daily dressing changes Adv: smoking cessation, pulmonary rehab. F/U PCP in 1 week for BP recheck. | Your medicines: (1) Tylenol (acetaminophen) 650mg every 6 hours as needed [do not exceed 3000mg/day]. (2) lisinopril 20mg once daily [blood pressure medicine]. (3) Eliquis 5mg twice daily [blood thinner]. (4) amlodipine 10mg once daily [blood pressure medicine]. (5) losartan 50mg once daily [blood pressure medicine]. A... | Cardiology | Prescription | high |
954 | HbA1c: 13.6% (H). FBS: 110 mg/dL (H). | Your diabetes blood test results: HbA1c is 13.6%, which is very high, meaning blood sugar has been dangerously uncontrolled (target is under 7%). Fasting blood sugar was 110, which is high (normal is 70-100). Urgent medication adjustment needed. Very high risk of diabetes complications at this level. | Endocrinology | Lab Result | high |
955 | CXR PA: Increased interstitial markings suggesting pulmonary edema. Bilateral hilar lymphadenopathy. Clear lung fields bilaterally. Pacemaker leads in appropriate position. Widened mediastinum. | Chest X-ray results: There are signs of extra fluid in the lung tissue, suggesting the heart may not be pumping efficiently [pulmonary edema]. There are enlarged lymph nodes at the root of both lungs, which needs further evaluation. Both lungs look clear with no problems. The pacemaker wires are in the correct position... | Pulmonology | Radiology Report | high |
956 | PATH: Breast: IDC, Nottingham grade 2, ER/PR positive, HER2 negative, margins negative. | Pathology results in plain language: Breast biopsy shows invasive ductal carcinoma, moderately aggressive. Hormone receptors positive (often treatable with hormone therapy). HER2 negative. Edges of tissue clear of cancer. | Oncology | Pathology Report | high |
957 | Rx: Tab lisinopril 10mg daily. Tab Xarelto 20mg daily with dinner. Adv: weight bearing exercise, calcium/vit D supplementation. F/U 4 weeks with TSH, Free T4. | Your medicines: (1) lisinopril 10mg once daily [blood pressure medicine that also protects kidneys]. (2) Xarelto 20mg once daily with dinner [blood thinner]. Advice: do weight-bearing exercises (walking, light weights) and take calcium and vitamin D for bone strength. Come back in 4 weeks for thyroid blood tests [TSH a... | Cardiology | Prescription | medium |
958 | Rx: Tab ciprofloxacin 500mg BID x 5 days. Tab methotrexate 15mg weekly. Tab clopidogrel 75mg daily. Tab furosemide 40mg daily. Adv: low salt low sugar diet, regular exercise. F/U PCP in 1 week for BP recheck. | Your medicines: (1) ciprofloxacin 500mg twice daily for 5 days [antibiotic — avoid dairy within 2 hours]. (2) methotrexate 15mg once weekly [immune-suppressing medicine for arthritis — requires monitoring]. (3) Plavix (clopidogrel) 75mg once daily [blood thinner]. (4) furosemide (Lasix) 40mg once daily [water pill to r... | Cardiology | Prescription | high |
959 | 53 y/o M with PMH of HFpEF, BPH, CAD, s/p THR, COPD, admitted for STEMI. ECG showed ST elevation. Troponin markedly elevated. Managed per protocol with improvement. Elevate R leg above heart level when resting. D/C on prednisone taper, albuterol MDI 2 puffs Q4-6H PRN, rosuvastatin 10mg QHS. F/U GI in 1 week. | A 53-year-old man with a history of heart failure with stiff heart muscle, enlarged prostate, coronary artery disease [heart artery blockages], prior hip replacement, and chronic lung disease was admitted for a serious heart attack requiring emergency treatment. ECG showed ST elevation. Troponin markedly elevated. They... | Cardiology | Discharge Summary | high |
960 | 72 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 72-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 |
961 | Delivery Note: G?P? at 37+3 weeks. Primary low-transverse C-section. Live female infant. APGAR 9/9. EBL within expected limits. Mother stable. | Birth summary: pregnancy reached about 37+3 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 |
962 | 45 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 45-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 |
963 | 88 y/o F presenting to ED with severe epigastric pain radiating to back, N/V x 6hrs. Vitals: BP 138/82, HR 108, RR 20, T 100.4F. Lipase 1800 (H). CT abdomen: peripancreatic fat stranding, no necrosis. Dx: Acute pancreatitis. NPO, aggressive IVF, IV morphine, IV pantoprazole. Admit medicine. | A 88-year-old woman came to the emergency room with severe upper belly pain shooting to the back with nausea and vomiting for 6 hours. Vital signs: blood pressure normal, heart rate fast, mild fever. Pancreas enzyme very high. CT scan showed severe pancreas inflammation but no dead tissue. Diagnosis: severe inflammatio... | Emergency Medicine | Clinical Note | high |
964 | Rx: prednisone taper. Tab pregabalin 75mg BID. albuterol MDI 2 puffs Q4-6H PRN. Tab warfarin 5mg daily. Adv: avoid alcohol, hepatotoxic drugs. F/U PCP in 1 week for BP recheck. | Your medicines: (1) prednisone steroid — dose gradually decreases as directed [do not stop suddenly]. (2) pregabalin 75mg twice daily [nerve pain medicine]. (3) albuterol inhaler 2 puffs every 4-6 hours as needed [rescue inhaler for breathing]. (4) warfarin 5mg once daily [blood thinner — requires regular INR blood tes... | Pulmonology | Prescription | high |
965 | 71 y/o F with PMH of cirrhosis, CKD Stage 3, anxiety, OA, CHF, admitted for acute kidney injury. Creatinine rose sharply from baseline. Managed per protocol with improvement. Low potassium diet. D/C on methotrexate 15mg weekly, potassium chloride 20mEq daily, metoprolol succinate 50mg daily, acetaminophen 650mg Q6H PRN... | A 71-year-old woman with a history of liver scarring [cirrhosis], moderate kidney disease, anxiety, arthritis [osteoarthritis], and heart failure was admitted for sudden worsening of kidney function. Kidney waste products rose sharply from baseline. They were treated according to standard guidelines and improved. Avoid... | Nephrology | Discharge Summary | high |
966 | 52 y/o F with PMH of CAD, s/p CABG, DVT/PE on warfarin, h/o TIA, osteoporosis, admitted for NSTEMI. Troponin elevated confirming heart muscle damage. Managed per protocol with improvement. Head injury precautions x 48hrs. D/C on warfarin 5mg daily, lisinopril 20mg daily. F/U neurology in 2 weeks. | A 52-year-old woman with a history of coronary artery disease [heart artery blockages], prior heart bypass surgery, blood clots [on blood thinner warfarin], history of mini-stroke, and weak bones [osteoporosis] was admitted for a type of heart attack (non-ST elevation myocardial infarction). A blood test (troponin) was... | Cardiology | Discharge Summary | high |
967 | LFTs: AST 457 (H), ALT 450 (H), ALP 76, T.Bili 3.1 (H), Albumin 4.8. | Your liver blood test results: Liver enzymes (AST 457, ALT 450) are severely elevated, indicating significant liver damage (normal is under 40). Bilirubin is high at 3.1 (normal under 1.2) — may cause yellowing of skin and eyes [jaundice]. Albumin is normal at 4.8. | Gastroenterology | Lab Result | high |
968 | Delivery Note: G?P? at 38+2 weeks. Primary low-transverse C-section. Live male infant. APGAR 7/9. 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 7/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
969 | Thyroid panel: TSH 3.94 (N), Free T4 1.2. | Your thyroid test results: TSH is normal at 3.94. Free T4 is normal — your thyroid function is balanced. | Endocrinology | Lab Result | medium |
970 | US Abdomen: Moderate right hydronephrosis. Right kidney 10.5cm, no hydronephrosis. No focal hepatic lesion. Liver 18cm, diffusely echogenic consistent with hepatic steatosis. | Abdominal ultrasound results: The right kidney is swollen because urine is backing up [hydronephrosis], possibly from a blockage. Right kidney is normal size with no blockage. No tumors or masses were found in the liver. The liver is slightly enlarged and appears brighter than normal, indicating fatty liver disease. | Gastroenterology | Radiology Report | high |
971 | Enoxaparin 40mg SC daily until walking regularly. | Injection helps prevent clots until you are walking normally. | General | Medication Instruction | medium |
972 | 23 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 23-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 |
973 | Procedure: ERCP with sphincterotomy. Pt 47 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 procedure to open the bile duct using a scope for a 47-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 |
974 | 37 y/o M with PMH of PAD, h/o TIA, COPD, depression, hypothyroidism, 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 spironolactone 25mg daily, Dulcolax 10mg QHS PRN, s... | A 37-year-old man with a history of poor blood flow in the legs [peripheral artery disease], history of mini-stroke, chronic lung disease, depression, and underactive thyroid was admitted for a serious blood infection from a skin infection. Blood cultures drawn. IV antibiotics started emergently. They were treated acco... | Infectious Disease | Discharge Summary | high |
975 | Rx: Tab gabapentin 300mg TID. Tab pantoprazole 40mg AC breakfast. Humalog per SSI. prednisone taper. Adv: DASH diet, daily BP monitoring. F/U 2 weeks with INR. | Your medicines: (1) gabapentin 300mg three times daily [nerve pain medicine — may cause drowsiness]. (2) pantoprazole 40mg before breakfast [acid-reducing medicine]. (3) Humalog insulin before meals as directed [fast-acting insulin]. (4) prednisone steroid — dose gradually decreases as directed [do not stop suddenly]. ... | Neurology | Prescription | high |
976 | 73 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 73-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 |
977 | BMP: Na 135 (L), K 3.9 (N), BUN 74, Cr 4.6 (H), Glucose 376. | Your blood chemistry results: Sodium is low at 135 (normal 136-145), meaning too much water in your body. Potassium is normal at 3.9. Creatinine is elevated at 4.6 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 376 (high). | Nephrology | Lab Result | high |
978 | Procedure: Laparoscopic cholecystectomy. 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 minimally invasive gallbladder removal for a 67-year-old woman. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | General Surgery | Procedure Note | high |
979 | Procedure: Port-a-cath placement. Pt 30 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 implanted vein port for chemotherapy for a 30-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. | Oncology | Procedure Note | high |
980 | CBC: WBC 8.3 (N), Hgb 8.7 (L), Plt 347 (N). | Your blood count results: White blood cells are 8.3 (normal). Hemoglobin is low at 8.7, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 347, which is normal. | Hematology | Lab Result | high |
981 | 30 y/o M with PMH of Parkinson's disease, s/p THR, seizure disorder on Keppra, admitted for acute stroke (CVA). CT showed acute ischemic infarct. tPA administered. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on furosemide 40mg BID, hydroxychloroquine 200mg BID, ondansetron 4mg... | A 30-year-old man with a history of Parkinson's disease, prior hip replacement, and seizure disorder [on Keppra] was admitted for a stroke [blocked blood vessel in the brain]. CT scan showed acute ischemic infarct. clot-dissolving medicine was given. They were treated according to standard guidelines and improved. Writ... | Neurology | Discharge Summary | high |
982 | 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 | high |
983 | 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 |
984 | CXR PA: ET tube 3cm above carina. Osseous structures intact. Increased interstitial markings suggesting pulmonary edema. | Chest X-ray results: The breathing tube is in good position. The bones look normal with no fractures. There are signs of extra fluid in the lung tissue, suggesting the heart may not be pumping efficiently [pulmonary edema]. | Pulmonology | Radiology Report | high |
985 | Procedure: Laparoscopic cholecystectomy. Pt 72 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 72-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 |
986 | 63 y/o M presenting to ED with RLQ pain x 12hrs, anorexia, low-grade fever. Vitals: BP 128/76, HR 96, T 100.8F. CT abdomen: 9mm dilated appendix with periappendiceal fat stranding, no perforation. Dx: Acute uncomplicated appendicitis. NPO, IV Zosyn. Surgery consulted for laparoscopic appendectomy. Admit surgery. | A 63-year-old man came to the emergency room with pain in the lower right belly for 12 hours, loss of appetite, and mild fever. Vital signs: blood pressure normal, heart rate slightly fast, mild fever. CT scan showed the appendix is swollen (9mm, normal <6mm) with inflammation around it but no rupture. Diagnosis: appen... | Emergency Medicine | Clinical Note | high |
987 | 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 |
988 | CBC: WBC 7.1 (N), Hgb 5.7 (L), Plt 34 (L). | Your blood count results: White blood cells are 7.1 (normal). Hemoglobin is low at 5.7, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 34, which is low — your blood may not clot properly, increasing bleeding risk. | Hematology | Lab Result | high |
989 | Delivery Note: G?P? at 39+1 weeks. Primary low-transverse C-section. Live male infant. APGAR 7/9. EBL within expected limits. Mother stable. | Birth summary: pregnancy reached about 39+1 weeks gestation. The baby was delivered by C-section through a low horizontal cut on the uterus. The newborn is a healthy male. APGAR scores were 7/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
990 | CBC: WBC 17.5 (H), Hgb 13.5 (N), Plt 307 (N). | Your blood count results: White blood cells are 17.5 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is normal at 13.5. Platelets are 307, which is normal. | Hematology | Lab Result | high |
991 | Rx: Tab calcium + vitamin D 600/400 daily. Tab methotrexate 15mg weekly. Tab amoxicillin 500mg TID x 10 days. Adv: SMBG BID, diabetic diet. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT. | Your medicines: (1) calcium plus vitamin D once daily [bone strengthening]. (2) methotrexate 15mg once weekly [immune-suppressing medicine for arthritis — requires monitoring]. (3) amoxicillin 500mg three times daily for 10 days [antibiotic — complete full course]. Advice: check your blood sugar twice daily and follow ... | Infectious Disease | Prescription | medium |
992 | 32 y/o F with PMH of HFrEF (EF 30%), s/p THR, admitted for alcohol withdrawal. CIWA protocol initiated. Lorazepam given as needed. Managed per protocol with improvement. Diabetic diet, SMBG BID. D/C on atorvastatin 40mg QHS, ondansetron 4mg Q8H PRN N/V, gabapentin 300mg TID. F/U GI in 1 week. | A 32-year-old woman with a history of heart failure with weak pumping (30%), and prior hip replacement was admitted for withdrawal symptoms after stopping alcohol. CIWA protocol initiated. Lorazepam given as needed. They were treated according to standard guidelines and improved. Follow a diabetes-friendly diet (limit ... | Psychiatry | Discharge Summary | high |
993 | 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 | low |
994 | 80 y/o M presenting to ED with severe epigastric pain radiating to back, N/V x 6hrs. Vitals: BP 138/82, HR 108, RR 20, T 100.4F. Lipase 1800 (H). CT abdomen: peripancreatic fat stranding, no necrosis. Dx: Acute pancreatitis. NPO, aggressive IVF, IV morphine, IV pantoprazole. Admit medicine. | A 80-year-old man came to the emergency room with severe upper belly pain shooting to the back with nausea and vomiting for 6 hours. Vital signs: blood pressure normal, heart rate fast, mild fever. Pancreas enzyme very high. CT scan showed severe pancreas inflammation but no dead tissue. Diagnosis: severe inflammation ... | Emergency Medicine | Clinical Note | high |
995 | 58 y/o M with PMH of ESRD on HD, OSA on CPAP, obesity (BMI 38), PPM in situ, admitted for sepsis secondary to cellulitis. Blood cultures drawn. IV antibiotics started emergently. Managed per protocol with improvement. Low potassium diet. D/C on rosuvastatin 10mg QHS, losartan 50mg daily. F/U orthopedics in 6 weeks with... | A 58-year-old man with a history of kidney failure requiring dialysis, sleep apnea [uses a breathing machine at night], obesity, and implanted pacemaker was admitted for a serious blood infection from a skin infection. Blood cultures drawn. IV antibiotics started emergently. They were treated according to standard guid... | Infectious Disease | Discharge Summary | high |
996 | Warfarin 5mg PO daily. INR goal 2.0-3.0. Avoid major diet changes in vitamin K. Report bleeding. | Take warfarin daily. Blood tests keep clotting in a safe range. Keep vitamin K intake steady and call your doctor for unusual bleeding. | Hematology | Medication Instruction | medium |
997 | 67 y/o M with PMH of asthma, HFrEF (EF 30%), admitted for chest pain r/o ACS. Serial troponins and cardiac monitoring performed. Managed per protocol with improvement. BRAT diet x 48hrs, advance as tolerated. D/C on carvedilol 12.5mg BID, clopidogrel 75mg daily, acetaminophen 650mg Q6H PRN, Xarelto 20mg daily with dinn... | A 67-year-old man with a history of asthma, and heart failure with weak pumping (30%) 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. Eat bland food for 48 hours (bananas, rice, a... | Cardiology | Discharge Summary | high |
998 | Rx: Tab empagliflozin 10mg daily. Tab warfarin 5mg daily. Tab timolol 0.5% OU BID. Tab methotrexate 15mg weekly. Adv: high fiber diet, adequate hydration Adv: smoking cessation, pulmonary rehab. F/U 1 week with wound check. | Your medicines: (1) empagliflozin 10mg once daily [blood sugar medicine that also protects heart and kidneys]. (2) warfarin 5mg once daily [blood thinner — requires regular INR blood tests]. (3) timolol eye drops in both eyes twice daily [lowers eye pressure for glaucoma]. (4) methotrexate 15mg once weekly [immune-supp... | Endocrinology | Prescription | high |
999 | HbA1c: 5.0% (N). FBS: 111 mg/dL (H). | Your diabetes blood test results: HbA1c is 5.0%, which is normal — you do not have diabetes. Fasting blood sugar was 111, which is high (normal is 70-100). No diabetes treatment needed. Continue healthy lifestyle. | Endocrinology | Lab Result | high |
1,000 | Rx: Tab carvedilol 12.5mg BID. Tab levothyroxine 75mcg daily on empty stomach. Do not stop abruptly, taper as directed Adv: avoid alcohol, hepatotoxic drugs. F/U 4 weeks with TSH, Free T4. | Your medicines: (1) carvedilol 12.5mg twice daily [heart medicine]. (2) levothyroxine 75mcg on empty stomach 30 min before breakfast [thyroid medicine]. Do not suddenly stop this medicine — your doctor will gradually reduce the dose if needed Advice: do not drink alcohol and avoid medications that can harm the liver (i... | Cardiology | Prescription | medium |
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