id int64 1 5k | source stringlengths 35 485 | target stringlengths 61 971 | specialty stringclasses 20
values | document_type stringclasses 9
values | complexity stringclasses 3
values |
|---|---|---|---|---|---|
101 | US Abdomen: No focal hepatic lesion. Spleen 16cm, splenomegaly. Pancreas unremarkable. Right kidney 10.5cm, no hydronephrosis. | Abdominal ultrasound results: No tumors or masses were found in the liver. The spleen is enlarged [splenomegaly]. The pancreas looks normal. Right kidney is normal size with no blockage. | Gastroenterology | Radiology Report | high |
102 | 69 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 69-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 |
103 | 36 y/o M presenting to ED with worst headache of my life, acute onset 2hrs ago. Vitals: BP 172/94, HR 78, GCS 15. CT Head: negative. LP: xanthochromic CSF, RBC 11000. CTA: 5mm ACOM aneurysm. Dx: SAH secondary to ruptured aneurysm. Nimodipine started. Neurosurgery consulted. Transfer to neuro ICU. | A 36-year-old man came to the emergency room with the worst headache of his/her life, started suddenly 2 hours ago. Vital signs: blood pressure elevated, heart rate normal, fully alert. CT scan did not show bleeding. Spinal tap showed blood in spinal fluid confirming brain bleed. Blood vessel scan found a 5mm bulge [an... | Emergency Medicine | Clinical Note | high |
104 | Rx: Tab Dulcolax 10mg QHS PRN. Tab entresto 49/51mg BID. Tab gabapentin 300mg TID. Tab carvedilol 12.5mg BID. Adv: weight bearing exercise, calcium/vit D supplementation Adv: fall precautions, home safety evaluation. F/U 6 weeks with LFTs. | Your medicines: (1) Dulcolax 10mg at bedtime as needed [for constipation]. (2) Entresto 49/51mg twice daily [heart failure medicine]. (3) gabapentin 300mg three times daily [nerve pain medicine — may cause drowsiness]. (4) carvedilol 12.5mg twice daily [heart medicine]. Advice: do weight-bearing exercises (walking, lig... | Cardiology | Prescription | high |
105 | CXR PA: No pneumothorax. Left lower lobe consolidation. Moderate right pleural effusion. Hyperinflated lungs consistent with COPD. Pacemaker leads in appropriate position. | Chest X-ray results: There is no collapsed lung. There is an area in the lower left lung that appears infected. There is a moderate amount of fluid around the right lung. The lungs appear over-inflated, which is typical of chronic lung disease [COPD/emphysema]. The pacemaker wires are in the correct position. | Pulmonology | Radiology Report | high |
106 | BMP: Na 148 (H), K 4.2 (N), BUN 74, Cr 2.7 (H), Glucose 226. | Your blood chemistry results: Sodium is high at 148, meaning you may be dehydrated. Potassium is normal at 4.2. Creatinine is elevated at 2.7 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 226 (high). | Nephrology | Lab Result | high |
107 | 53 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 53-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 |
108 | 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 |
109 | Procedure: R TKA. Pt 78 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 78-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 |
110 | HbA1c: 8.7% (H). FBS: 324 mg/dL (H). | Your diabetes blood test results: HbA1c is 8.7%, which is high, meaning your blood sugar has been poorly controlled over the past 3 months (target is under 7%). Fasting blood sugar was 324, which is high (normal is 70-100). Your diabetes treatment needs to be changed. This level increases risk of complications. | Endocrinology | Lab Result | high |
111 | US Abdomen: Pancreas unremarkable. Ascites moderate amount. Spleen 11cm, normal. | Abdominal ultrasound results: The pancreas looks normal. There is a moderate amount of fluid in the belly [ascites]. The spleen is a normal size. | Gastroenterology | Radiology Report | high |
112 | 77 y/o M with PMH of cirrhosis, A-fib, CHF, RA on MTX, admitted for GI bleeding. Hemoglobin dropped. Required blood transfusion. Managed per protocol with improvement. Elevate R leg above heart level when resting. D/C on Augmentin 875/125 BID x 7 days, ferrous sulfate 325mg BID, omeprazole 20mg AC breakfast, metformin ... | A 77-year-old man with a history of liver scarring [cirrhosis], irregular heartbeat [atrial fibrillation], heart failure, and rheumatoid arthritis [on immune-suppressing medicine] was admitted for bleeding in the digestive tract. Blood count dropped. Required blood transfusion. They were treated according to standard g... | Gastroenterology | Discharge Summary | high |
113 | 30 y/o F with PMH of seizure disorder on Keppra, ESRD on HD, admitted for NSTEMI. Troponin elevated confirming heart muscle damage. Managed per protocol with improvement. Wound care: daily dressing changes with wet-to-dry gauze. D/C on lisinopril 10mg daily, pregabalin 75mg BID, acetaminophen 650mg Q6H PRN, omeprazole ... | A 30-year-old woman with a history of seizure disorder [on Keppra], and kidney failure requiring dialysis was admitted for a type of heart attack (non-ST elevation myocardial infarction). A blood test (troponin) was elevated confirming heart muscle damage. They were treated according to standard guidelines and improved... | Cardiology | Discharge Summary | high |
114 | HbA1c: 6.2% (H). FBS: 101 mg/dL (H). | Your diabetes blood test results: HbA1c is 6.2%, which is in the pre-diabetes range (5.7-6.4%). This means your blood sugar is higher than normal but not yet diabetic. Fasting blood sugar was 101, which is high (normal is 70-100). Lifestyle changes (diet, exercise, weight loss) can prevent progression to diabetes. | Endocrinology | Lab Result | high |
115 | Delivery Note: G?P? at 37+3 weeks. Primary low-transverse C-section. Live female infant. APGAR 7/9. 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 7/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
116 | Rx: Tab metformin 1000mg BID. Tab levothyroxine 75mcg daily on empty stomach. Tab ASA 81mg daily. Tab metoprolol 25mg BID. Tab acetaminophen 650mg Q6H PRN. Adv: low potassium diet. F/U 2 weeks with INR. | Your medicines: (1) metformin 1000mg twice daily with meals [blood sugar medicine]. (2) levothyroxine 75mcg on empty stomach 30 min before breakfast [thyroid medicine]. (3) baby aspirin 81mg once daily [prevents blood clots]. (4) metoprolol 25mg twice daily [slows heart rate and lowers blood pressure]. (5) Tylenol (ace... | Cardiology | Prescription | high |
117 | CBC: WBC 10.9 (N), Hgb 14.9 (N), Plt 164 (N). | Your blood count results: White blood cells are 10.9 (normal). Hemoglobin is normal at 14.9. Platelets are 164, which is normal. | Hematology | Lab Result | medium |
118 | BMP: Na 123 (L), K 4.3 (N), BUN 69, Cr 3.0 (H), Glucose 248. | Your blood chemistry results: Sodium is low at 123 (normal 136-145), meaning too much water in your body. Potassium is normal at 4.3. Creatinine is elevated at 3.0 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 248 (high). | Nephrology | Lab Result | high |
119 | 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 |
120 | 53 y/o M presenting to ED with seizure witnessed by family, GTC x 3 min, postictal x 15 min. Vitals: BP 152/88, HR 98, T 98.6F, GCS 14 (postictal). CT Head: no hemorrhage. BMP: Na 128 (L). Keppra level <5 (subtherapeutic). Known seizure disorder, off meds x 1 week. Dx: Breakthrough seizure secondary to medication nonco... | A 53-year-old man came to the emergency room with a full-body seizure witnessed by family lasting about 3 minutes, followed by 15 minutes of confusion. Vital signs: blood pressure elevated (from seizure), heart rate slightly fast, no fever, mostly alert but still slightly confused. CT scan shows no bleeding. Sodium is ... | Emergency Medicine | Clinical Note | high |
121 | HbA1c: 11.2% (H). FBS: 336 mg/dL (H). | Your diabetes blood test results: HbA1c is 11.2%, which is very high, meaning blood sugar has been dangerously uncontrolled (target is under 7%). Fasting blood sugar was 336, which is high (normal is 70-100). Urgent medication adjustment needed. Very high risk of diabetes complications at this level. | Endocrinology | Lab Result | high |
122 | 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 |
123 | 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 |
124 | Delivery Note: G?P? at 40+0 weeks. SVD. Live female infant. APGAR 9/9. 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 female. APGAR scores were 9/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
125 | 91 y/o F with PMH of obesity (BMI 38), GERD, DVT/PE on warfarin, CHF, admitted for STEMI. ECG showed ST elevation. Troponin markedly elevated. Managed per protocol with improvement. Low potassium diet. D/C on ASA 81mg daily, calcium + vitamin D 600/400 daily, Dulcolax 10mg QHS PRN, atorvastatin 80mg QHS. F/U endocrine ... | A 91-year-old woman with a history of obesity, acid reflux, blood clots [on blood thinner warfarin], and heart failure was admitted for a serious heart attack requiring emergency treatment. ECG showed ST elevation. Troponin markedly elevated. They were treated according to standard guidelines and improved. Avoid high-p... | Cardiology | Discharge Summary | high |
126 | 72 y/o F with PMH of gout, CHF, A-fib, admitted for NSTEMI. Troponin elevated confirming heart muscle damage. Managed per protocol with improvement. Strict NPO after midnight before procedure. D/C on levothyroxine 75mcg daily on empty stomach, losartan 50mg daily, atorvastatin 80mg QHS. F/U nephrology in 1 week. | A 72-year-old woman with a history of gout, heart failure, and irregular heartbeat [atrial fibrillation] was admitted for a type of heart attack (non-ST elevation myocardial infarction). A blood test (troponin) was elevated confirming heart muscle damage. They were treated according to standard guidelines and improved.... | Cardiology | Discharge Summary | high |
127 | Rx: Tab metoprolol succinate 50mg daily. Tab potassium chloride 20mEq daily. Tab metformin 500mg BID. Tab losartan 50mg daily. Tab atorvastatin 80mg QHS. Do not stop abruptly, taper as directed Adv: fall precautions, home safety evaluation. F/U 1 week with wound check. | Your medicines: (1) metoprolol 50mg once daily [heart rate and blood pressure medicine]. (2) potassium supplement 20mEq once daily [replaces potassium lost from water pills]. (3) metformin 500mg twice daily with meals [blood sugar medicine]. (4) losartan 50mg once daily [blood pressure medicine]. (5) atorvastatin 80mg ... | Pediatrics | Prescription | high |
128 | Procedure: Colonoscopy with polypectomy. Pt 87 y/o F. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes colon exam with removal of polyps for a 87-year-old woman. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | Gastroenterology | Procedure Note | high |
129 | 79 y/o M with PMH of ICD in situ, s/p TKR, Parkinson's disease, ESRD on HD, asthma, admitted for small bowel obstruction. CT showed dilated loops of bowel with transition point. Managed per protocol with improvement. Daily weights, 1.5L fluid restriction, low sodium diet. D/C on spironolactone 25mg daily, metoprolol su... | A 79-year-old man with a history of implanted heart defibrillator, prior knee replacement, Parkinson's disease, kidney failure requiring dialysis, and asthma was admitted for a blockage in the small intestine. CT scan showed dilated loops of bowel with transition point. They were treated according to standard guideline... | General Surgery | Discharge Summary | high |
130 | 29 y/o F with PMH of DM2, s/p TKR, OA, depression, CKD Stage 4, admitted for upper GI bleeding. Hematemesis noted. EGD showed bleeding ulcer. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on acetaminophen 650mg Q6H PRN, atorvastatin 80mg QHS, amlodipine 5mg daily, calciu... | A 29-year-old woman with a history of type 2 diabetes, prior knee replacement, arthritis [osteoarthritis], depression, and advanced kidney disease was admitted for bleeding from the stomach or food pipe. Hematemesis noted. EGD showed bleeding ulcer. They were treated according to standard guidelines and improved. Use t... | Gastroenterology | Discharge Summary | high |
131 | MRI Lumbar Spine: Conus medullaris at L1, normal. C5-C6 disc herniation with cord compression. Facet joint hypertrophy at L4-L5. No compression fracture. | MRI of the lower back results: The spinal cord ends at a normal level. At C5-C6 in the neck, a disc has pushed out and is pressing on the spinal cord — this is significant. The small joints in the spine at L4-L5 are enlarged from arthritis. No bones are broken or collapsed. | Orthopedics | Radiology Report | high |
132 | 66 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 66-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 |
133 | 35 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 35-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 |
134 | MRI Lumbar Spine: Central canal stenosis at L3-L4. No compression fracture. | MRI of the lower back results: The spinal canal is narrowed at L3-L4, which may be pressing on the nerves. No bones are broken or collapsed. | Orthopedics | Radiology Report | high |
135 | LFTs: AST 232 (H), ALT 198 (H), ALP 191, T.Bili 5.5 (H), Albumin 2.6. | Your liver blood test results: Liver enzymes (AST 232, ALT 198) are moderately elevated, indicating liver irritation (normal is under 40). Bilirubin is high at 5.5 (normal under 1.2) — may cause yellowing of skin and eyes [jaundice]. Albumin is low at 2.6 (normal 3.5-5.5), suggesting the liver is struggling to make imp... | Gastroenterology | Lab Result | high |
136 | 58 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 58-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 |
137 | CXR PA: Port-a-cath in appropriate position. ET tube 3cm above carina. Pacemaker leads in appropriate position. Increased interstitial markings suggesting pulmonary edema. Widened mediastinum. | Chest X-ray results: The implanted medication port is in the correct position. The breathing tube is in good position. The pacemaker wires are in the correct position. There are signs of extra fluid in the lung tissue, suggesting the heart may not be pumping efficiently [pulmonary edema]. The space between the lungs ap... | Pulmonology | Radiology Report | high |
138 | 76 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 76-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 |
139 | Procedure: TURP for BPH. Pt 25 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 25-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 |
140 | 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 |
141 | 45 y/o F with PMH of 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 prednisone taper, ASA 81mg daily, omeprazole 20mg AC breakfast. F/U GI in 1 week. | A 45-year-old woman with a history of 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 standard guidelines and improved. Be careful to prev... | Cardiology | Discharge Summary | high |
142 | PATH: LN bx: reactive lymphoid hyperplasia, no evidence of lymphoma. | Pathology results in plain language: Lymph node sample shows reactive swelling from infection/inflammation, not lymphoma. | Hematology | Pathology Report | high |
143 | 66 y/o M with PMH of s/p CABG, obesity (BMI 38), HFpEF, admitted for pneumonia. CXR confirmed infiltrate. Started on IV antibiotics. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on metoprolol 25mg BID, ondansetron 4mg Q8H PRN N/V, metoprolol succinate 50mg daily. F/U endocrine in 1 week. | A 66-year-old man with a history of prior heart bypass surgery, obesity, and heart failure with stiff heart muscle was admitted for a lung infection. CXR confirmed infiltrate. Started on IV antibiotics. They were treated according to standard guidelines and improved. Be careful to prevent falls. Physical therapy and oc... | Pulmonology | Discharge Summary | high |
144 | MRI Lumbar Spine: Conus medullaris at L1, normal. Facet joint hypertrophy at L4-L5. L4-L5 disc herniation with moderate bilateral foraminal stenosis. | MRI of the lower back results: The spinal cord ends at a normal level. The small joints in the spine at L4-L5 are enlarged from arthritis. At the L4-L5 level, a disc has pushed outward [herniated] and is narrowing the nerve tunnels on both sides. | Orthopedics | Radiology Report | high |
145 | Lipid panel: TC 288, LDL 182, HDL 25, TG 339. | Your cholesterol results: Total cholesterol is 288. LDL (bad cholesterol) is very high at 182 (goal under 100), significantly increasing heart disease risk. HDL (good cholesterol) is too low at 25 (should be above 40 for men, 50 for women) — this is a risk factor for heart disease. Triglycerides are very high at 339 (n... | Cardiology | Lab Result | high |
146 | 52 y/o F with PMH of DVT/PE on warfarin, BPH, COPD, s/p CABG, anxiety, admitted for hypertensive urgency. BP 210/120. IV medications started to lower gradually. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on ASA 81mg daily, metoprolol 25mg BID, clopidogrel 75mg daily, furosemi... | A 52-year-old woman with a history of blood clots [on blood thinner warfarin], enlarged prostate, chronic lung disease, prior heart bypass surgery, and anxiety was admitted for dangerously high blood pressure. BP 210/120. IV medications started to lower gradually. They were treated according to standard guidelines and ... | Cardiology | Discharge Summary | high |
147 | 87 y/o F with PMH of OA, HLD, admitted for upper GI bleeding. Hematemesis noted. EGD showed bleeding ulcer. Managed per protocol with improvement. Compression stockings when ambulating. D/C on Spiriva 18mcg daily, pantoprazole 40mg AC breakfast, losartan 50mg daily, levothyroxine 75mcg daily on empty stomach, metoprolo... | A 87-year-old woman with a history of arthritis [osteoarthritis], and high cholesterol 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. Wear compression stockings on your legs when walking to prevent b... | Gastroenterology | Discharge Summary | high |
148 | 88 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 88-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 |
149 | CXR PA: Clear lung fields bilaterally. No cardiomegaly. ET tube 3cm above carina. Patchy bilateral infiltrates. Elevated left hemidiaphragm. | Chest X-ray results: Both lungs look clear with no problems. The heart is a normal size. The breathing tube is in good position. There are scattered cloudy patches in both lungs suggesting infection or inflammation. The left side of the breathing muscle [diaphragm] is sitting higher than normal. | Pulmonology | Radiology Report | high |
150 | 48 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 48-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 |
151 | CBC: WBC 6.6 (N), Hgb 16.6 (N), Plt 238 (N). | Your blood count results: White blood cells are 6.6 (normal). Hemoglobin is normal at 16.6. Platelets are 238, which is normal. | Hematology | Lab Result | medium |
152 | 73 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 73-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 |
153 | CT Head without contrast: Paranasal sinuses clear. 4cm right subdural hematoma with 5mm midline shift. Subarachnoid hemorrhage in bilateral sylvian fissures. No mass effect. | CT scan of the head results: The sinuses are clear with no infection. 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 bleeding around the brain surface, particularly in the grooves on both sides. There are no tumo... | Neurology | Radiology Report | high |
154 | CXR PA: No pneumothorax. Port-a-cath in appropriate position. Sternotomy wires intact. | Chest X-ray results: There is no collapsed lung. The implanted medication port is in the correct position. The wires from prior heart surgery are intact. | Pulmonology | Radiology Report | high |
155 | 57 y/o F with PMH of depression, CKD Stage 3, admitted for GI bleeding. Hemoglobin dropped. Required blood transfusion. Managed per protocol with improvement. BRAT diet x 48hrs, advance as tolerated. D/C on methotrexate 15mg weekly, latanoprost 0.005% OU QHS, entresto 49/51mg BID, furosemide 40mg BID, calcium + vitamin... | A 57-year-old woman with a history of depression, and moderate kidney disease was admitted for bleeding in the digestive tract. Blood count dropped. Required blood transfusion. They were treated according to standard guidelines and improved. Eat bland food for 48 hours (bananas, rice, applesauce, toast), then slowly re... | Gastroenterology | Discharge Summary | high |
156 | 38 y/o F with PMH of asthma, HTN, COPD, PPM in situ, admitted for sepsis secondary to UTI. Blood cultures positive. Lactate elevated. Managed per protocol with improvement. Wound care: daily dressing changes with wet-to-dry gauze. D/C on acetaminophen 650mg Q6H PRN, gabapentin 300mg TID, Xarelto 20mg daily with dinner.... | A 38-year-old woman with a history of asthma, high blood pressure, chronic lung disease, and implanted pacemaker was admitted for a serious blood infection from a urinary tract infection. Blood test showed bacteria in the blood. A marker of infection severity was high. They were treated according to standard guidelines... | Infectious Disease | Discharge Summary | high |
157 | 89 y/o M with PMH of A-fib, CKD Stage 3, asthma, COPD, admitted for alcohol withdrawal. CIWA protocol initiated. Lorazepam given as needed. Managed per protocol with improvement. Wound care: daily dressing changes with wet-to-dry gauze. D/C on Dulcolax 10mg QHS PRN, Spiriva 18mcg daily. F/U surgery in 2 weeks for drain... | A 89-year-old man with a history of irregular heartbeat [atrial fibrillation], moderate kidney disease, asthma, and chronic lung disease was admitted for withdrawal symptoms after stopping alcohol. CIWA protocol initiated. Lorazepam given as needed. They were treated according to standard guidelines and improved. Chang... | Psychiatry | Discharge Summary | high |
158 | CXR PA: ET tube 3cm above carina. Left lower lobe consolidation. Small left pleural effusion. | Chest X-ray results: The breathing tube is in good position. There is an area in the lower left lung that appears infected. There is a small amount of fluid around the left lung. | Pulmonology | Radiology Report | high |
159 | CBC: WBC 17.6 (H), Hgb 13.2 (N), Plt 193 (N). | Your blood count results: White blood cells are 17.6 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is normal at 13.2. Platelets are 193, which is normal. | Hematology | Lab Result | high |
160 | Procedure: Laparoscopic cholecystectomy. Pt 22 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 22-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 |
161 | Rx: Tab ciprofloxacin 500mg BID x 5 days. Tab warfarin 5mg daily. Adv: weight bearing exercise, calcium/vit D supplementation. F/U 1 month with repeat imaging. | Your medicines: (1) ciprofloxacin 500mg twice daily for 5 days [antibiotic — avoid dairy within 2 hours]. (2) warfarin 5mg once daily [blood thinner — requires regular INR blood tests]. Advice: do weight-bearing exercises (walking, light weights) and take calcium and vitamin D for bone strength. Come back in 1 month — ... | Infectious Disease | Prescription | medium |
162 | Procedure: Laparoscopic appendectomy. Pt 53 y/o F. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes keyhole surgery to remove the appendix for a 53-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 |
163 | 76 y/o M with PMH of GERD, obesity (BMI 38), OSA on CPAP, PPM in situ, admitted for acute pancreatitis. Lipase markedly elevated. CT showed peripancreatic inflammation. Managed per protocol with improvement. Strict I&O, daily weights. D/C on montelukast 10mg QHS, omeprazole 20mg AC breakfast, amlodipine 10mg daily, ibu... | A 76-year-old man with a history of acid reflux, obesity, sleep apnea [uses a breathing machine at night], and implanted pacemaker 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 imp... | Gastroenterology | Discharge Summary | high |
164 | 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 |
165 | LFTs: AST 49 (H), ALT 45 (H), ALP 83, T.Bili 5.1 (H), Albumin 3.9. | Your liver blood test results: Liver enzymes (AST 49, ALT 45) are mildly elevated (normal is under 40). Bilirubin is high at 5.1 (normal under 1.2) — may cause yellowing of skin and eyes [jaundice]. Albumin is normal at 3.9. | Gastroenterology | Lab Result | high |
166 | 84 y/o F with PMH of ESRD on HD, A-fib, hypothyroidism, CKD Stage 4, admitted for PE. CTA positive for PE. Heparin started. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on glipizide 5mg BID AC, hydroxychloroquine 200mg BID, Spiriva 18mcg daily. F/U surgery in 10 days. | A 84-year-old woman with a history of kidney failure requiring dialysis, irregular heartbeat [atrial fibrillation], underactive thyroid, and advanced kidney disease was admitted for a blood clot in the lungs [pulmonary embolism]. CT scan confirmed a blood clot in the lungs. Heparin started. They were treated according ... | Pulmonology | Discharge Summary | high |
167 | Levetiracetam 500mg BID; do not stop suddenly; report mood changes. | Anti-seizure medicine twice daily; taper only with clinician guidance; watch for mood side effects. | Neurology | Medication Instruction | high |
168 | CXR PA: Small left pleural effusion. Widened mediastinum. Elevated left hemidiaphragm. | Chest X-ray results: There is a small amount of fluid around the left lung. The space between the lungs appears wider than normal, which needs further evaluation. The left side of the breathing muscle [diaphragm] is sitting higher than normal. | Pulmonology | Radiology Report | high |
169 | 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 |
170 | 22 y/o M presenting to ED with seizure witnessed by family, GTC x 3 min, postictal x 15 min. Vitals: BP 152/88, HR 98, T 98.6F, GCS 14 (postictal). CT Head: no hemorrhage. BMP: Na 128 (L). Keppra level <5 (subtherapeutic). Known seizure disorder, off meds x 1 week. Dx: Breakthrough seizure secondary to medication nonco... | A 22-year-old man came to the emergency room with a full-body seizure witnessed by family lasting about 3 minutes, followed by 15 minutes of confusion. Vital signs: blood pressure elevated (from seizure), heart rate slightly fast, no fever, mostly alert but still slightly confused. CT scan shows no bleeding. Sodium is ... | Emergency Medicine | Clinical Note | high |
171 | MRI Lumbar Spine: Multilevel degenerative disc disease. No compression fracture. | MRI of the lower back results: Multiple discs in the spine are showing wear and aging. No bones are broken or collapsed. | Orthopedics | Radiology Report | high |
172 | 47 y/o F presenting to ED with acute onset pleuritic CP, SOB, R calf swelling x 3 days. Vitals: BP 132/88, HR 112, RR 24, O2 91% on RA. D-dimer elevated. CTA chest: bilateral PE with RV strain. US R LE: popliteal DVT. Dx: Bilateral PE with DVT. Heparin drip started. Consider catheter-directed thrombolysis given RV stra... | A 47-year-old woman came to the emergency room with sudden chest pain that worsens with breathing, shortness of breath, and right calf swelling for 3 days. Vital signs: blood pressure normal, heart rate fast, breathing rapid, oxygen low at 91%. A blood clot screening test was positive. CT scan confirmed blood clots in ... | Emergency Medicine | Clinical Note | high |
173 | Rx: Tab tramadol 50mg Q6H PRN pain. Tab metoprolol succinate 50mg daily. albuterol MDI 2 puffs Q4-6H PRN. Tab atorvastatin 80mg QHS. Tab amlodipine 10mg daily. Adv: smoking cessation, pulmonary rehab. 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) metoprolol 50mg once daily [heart rate and blood pressure medicine]. (3) albuterol inhaler 2 puffs every 4-6 hours as needed [rescue inhaler for breathing]. (4) atorvastatin 80mg at bedtime [high-dose cholesterol ... | Cardiology | Prescription | high |
174 | Latanoprost OU QHS; remove contacts before drops; punctal occlusion 1 min. | Glaucoma drops at bedtime in both eyes; remove contacts before use and gently press inner corners for one minute. | Ophthalmology | Medication Instruction | low |
175 | Procedure: R TKA. Pt 65 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 65-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 |
176 | CT Head without contrast: No mass effect. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. No midline shift. | CT scan of the head results: There are no tumors or masses pushing on the brain. There are aging-related changes in the brain's white matter from reduced blood flow to small vessels over time. The brain is centered normally. | Neurology | Radiology Report | high |
177 | 45 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 45-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 |
178 | 31 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 31-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 |
179 | 56 y/o M presenting to ED with seizure witnessed by family, GTC x 3 min, postictal x 15 min. Vitals: BP 152/88, HR 98, T 98.6F, GCS 14 (postictal). CT Head: no hemorrhage. BMP: Na 128 (L). Keppra level <5 (subtherapeutic). Known seizure disorder, off meds x 1 week. Dx: Breakthrough seizure secondary to medication nonco... | A 56-year-old man came to the emergency room with a full-body seizure witnessed by family lasting about 3 minutes, followed by 15 minutes of confusion. Vital signs: blood pressure elevated (from seizure), heart rate slightly fast, no fever, mostly alert but still slightly confused. CT scan shows no bleeding. Sodium is ... | Emergency Medicine | Clinical Note | high |
180 | 85 y/o M with PMH of SLE, s/p CABG, s/p THR, BPH, admitted for STEMI. ECG showed ST elevation. Troponin markedly elevated. Managed per protocol with improvement. Strict I&O, daily weights. D/C on prednisone taper, levothyroxine 75mcg daily on empty stomach. F/U oncology in 1 week. | A 85-year-old man with a history of lupus, prior heart bypass surgery, prior hip replacement, and enlarged prostate was admitted for a serious heart attack requiring emergency treatment. ECG showed ST elevation. Troponin markedly elevated. They were treated according to standard guidelines and improved. Track how much ... | Cardiology | Discharge Summary | high |
181 | Rx: Tab levothyroxine 75mcg daily on empty stomach. Tab warfarin 5mg daily. Tab amlodipine 5mg daily. Adv: low potassium diet Adv: DASH diet, daily BP monitoring. F/U 1 month with repeat imaging. | Your medicines: (1) levothyroxine 75mcg on empty stomach 30 min before breakfast [thyroid medicine]. (2) warfarin 5mg once daily [blood thinner — requires regular INR blood tests]. (3) amlodipine 5mg once daily [blood pressure medicine]. Advice: avoid high-potassium foods like bananas, oranges, potatoes, and tomatoes A... | Cardiology | Prescription | medium |
182 | 60 y/o F with PMH of CKD Stage 3, DM1, admitted for STEMI. ECG showed ST elevation. Troponin markedly elevated. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on sertraline 50mg daily, atorvastatin 40mg QHS, amlodipine 10mg daily, empagliflozin 10mg daily. F/U surgery in ... | A 60-year-old woman with a history of moderate kidney disease, and type 1 diabetes was admitted for a serious heart attack requiring emergency treatment. ECG showed ST elevation. Troponin markedly elevated. They were treated according to standard guidelines and improved. Use the breathing exercise device every hour whi... | Cardiology | Discharge Summary | high |
183 | 50 y/o F with PMH of anemia, Parkinson's disease, CAD, ESRD on HD, admitted for GI bleeding. Hemoglobin dropped. Required blood transfusion. Managed per protocol with improvement. Smoking cessation counseling provided. D/C on albuterol MDI 2 puffs Q4-6H PRN, prednisone taper. F/U nephrology in 1 week. | A 50-year-old woman with a history of low blood count [anemia], Parkinson's disease, coronary artery disease [heart artery blockages], and kidney failure requiring dialysis was admitted for bleeding in the digestive tract. Blood count dropped. Required blood transfusion. They were treated according to standard guidelin... | Gastroenterology | Discharge Summary | high |
184 | 30 y/o M with PMH of s/p TKR, obesity (BMI 38), cirrhosis, OA, HFpEF, admitted for acute stroke (CVA). CT showed acute ischemic infarct. tPA administered. Managed per protocol with improvement. Strict I&O, daily weights. D/C on hydroxychloroquine 200mg BID, potassium chloride 20mEq daily. F/U orthopedics in 6 weeks wit... | A 30-year-old man with a history of prior knee replacement, obesity, liver scarring [cirrhosis], arthritis [osteoarthritis], and heart failure with stiff heart muscle was admitted for a stroke [blocked blood vessel in the brain]. CT scan showed acute ischemic infarct. clot-dissolving medicine was given. They were treat... | Neurology | Discharge Summary | high |
185 | Procedure: Laparoscopic cholecystectomy. Pt 70 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 70-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 |
186 | CXR PA: Bilateral pleural effusions. Cardiomegaly with CTR >0.5. Osseous structures intact. | Chest X-ray results: There is fluid collecting around both lungs. The heart appears larger than normal. The bones look normal with no fractures. | Pulmonology | Radiology Report | high |
187 | Rx: Tab ciprofloxacin 500mg BID x 5 days. Tab amoxicillin 500mg TID x 10 days. Tab metformin 500mg BID. Adv: weight bearing exercise, calcium/vit D supplementation Adv: fall precautions, home safety evaluation. F/U 6 weeks with LFTs. | Your medicines: (1) ciprofloxacin 500mg twice daily for 5 days [antibiotic — avoid dairy within 2 hours]. (2) amoxicillin 500mg three times daily for 10 days [antibiotic — complete full course]. (3) metformin 500mg twice daily with meals [blood sugar medicine]. Advice: do weight-bearing exercises (walking, light weight... | Infectious Disease | Prescription | medium |
188 | 40 y/o M with PMH of HTN, s/p THR, admitted for chest pain r/o ACS. Serial troponins and cardiac monitoring performed. Managed per protocol with improvement. Low potassium diet. D/C on albuterol MDI 2 puffs Q4-6H PRN, Spiriva 18mcg daily, amlodipine 5mg daily, carvedilol 12.5mg BID, Lantus 20U QHS. F/U oncology in 1 we... | A 40-year-old man with a history of high blood pressure, and prior hip replacement was admitted for chest pain being evaluated for a possible heart attack. Serial troponins and cardiac monitoring performed. They were treated according to standard guidelines and improved. Avoid high-potassium foods: bananas, oranges, po... | Cardiology | Discharge Summary | high |
189 | CXR PA: Right middle lobe atelectasis. Left lower lobe consolidation. Compression fracture T12. Small left pleural effusion. | Chest X-ray results: Part of the right lung has partially collapsed [atelectasis], possibly from mucus plugging. There is an area in the lower left lung that appears infected. There is a compression fracture [collapsed bone] in the lower spine at T12. There is a small amount of fluid around the left lung. | Pulmonology | Radiology Report | high |
190 | 47 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 47-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 |
191 | Procedure: TURP for BPH. Pt 38 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 38-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 |
192 | 73 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 73-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 |
193 | 25 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 25-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 |
194 | 72 y/o M with PMH of ESRD on HD, h/o CVA, admitted for acute stroke (CVA). CT showed acute ischemic infarct. tPA administered. Managed per protocol with improvement. BRAT diet x 48hrs, advance as tolerated. D/C on acetaminophen 650mg Q6H PRN, Dulcolax 10mg QHS PRN, Augmentin 875/125 BID x 7 days, calcium + vitamin D 60... | A 72-year-old man with a history of kidney failure requiring dialysis, and history of stroke 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. Eat bland food for 48 ho... | Neurology | Discharge Summary | high |
195 | 37 y/o F with PMH of CKD Stage 4, asthma, admitted for acute kidney injury. Creatinine rose sharply from baseline. Managed per protocol with improvement. Strict I&O, daily weights. D/C on clopidogrel 75mg daily, Xarelto 20mg daily with dinner, carvedilol 12.5mg BID, omeprazole 20mg AC breakfast, metformin 1000mg BID. F... | A 37-year-old woman with a history of advanced kidney disease, and asthma was admitted for sudden worsening of kidney function. Kidney waste products rose sharply from baseline. They were treated according to standard guidelines and improved. Track how much you drink and urinate. Weigh yourself every morning.. Medicati... | Nephrology | Discharge Summary | high |
196 | Rx: Tab levothyroxine 75mcg daily on empty stomach. Tab pantoprazole 40mg AC breakfast. Do not stop abruptly, taper as directed Adv: weight bearing exercise, calcium/vit D supplementation. F/U PCP in 1 week for BP recheck. | Your medicines: (1) levothyroxine 75mcg on empty stomach 30 min before breakfast [thyroid medicine]. (2) pantoprazole 40mg before breakfast [acid-reducing medicine]. Do not suddenly stop this medicine — your doctor will gradually reduce the dose if needed Advice: do weight-bearing exercises (walking, light weights) and... | Gastroenterology | Prescription | medium |
197 | CT Head without contrast: Chronic lacunar infarcts in bilateral basal ganglia. No mass effect. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. No midline shift. | CT scan of the head results: There are signs of small old strokes in the deep parts of the brain. There are no tumors or masses pushing on the brain. There are aging-related changes in the brain's white matter from reduced blood flow to small vessels over time. The brain is centered normally. | Neurology | Radiology Report | high |
198 | HbA1c: 11.9% (H). FBS: 155 mg/dL (H). | Your diabetes blood test results: HbA1c is 11.9%, which is very high, meaning blood sugar has been dangerously uncontrolled (target is under 7%). Fasting blood sugar was 155, which is high (normal is 70-100). Urgent medication adjustment needed. Very high risk of diabetes complications at this level. | Endocrinology | Lab Result | high |
199 | 29 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 29-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 |
200 | Rx: Tab rosuvastatin 10mg QHS. Tab ibuprofen 400mg Q6H PRN with food. Humalog per SSI. Adv: high fiber diet, adequate hydration. F/U 1 week with wound check. | Your medicines: (1) rosuvastatin 10mg at bedtime [cholesterol medicine]. (2) ibuprofen 400mg every 6 hours as needed with food [anti-inflammatory pain reliever]. (3) Humalog insulin before meals as directed [fast-acting insulin]. Advice: eat plenty of fiber (fruits, vegetables, whole grains) and drink enough water. Com... | Cardiology | Prescription | medium |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.