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201 | 44 y/o F with PMH of HFpEF, ESRD on HD, gout, depression, admitted for AECOPD. O2 sat dropped. Required supplemental oxygen. Managed per protocol with improvement. Smoking cessation counseling provided. D/C on escitalopram 10mg daily, atorvastatin 40mg QHS, azithromycin 500mg day 1 then 250mg x 4 days. F/U hematology i... | A 44-year-old woman with a history of heart failure with stiff heart muscle, kidney failure requiring dialysis, gout, and depression was admitted for a severe flare-up of chronic lung disease. Oxygen levels dropped. Required supplemental oxygen. They were treated according to standard guidelines and improved. Strongly ... | Pulmonology | Discharge Summary | high |
202 | 55 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 55-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 |
203 | 45 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 45-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 |
204 | 84 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 84-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 |
205 | 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 |
206 | Rx: albuterol MDI 2 puffs Q4-6H PRN. Tab metformin 500mg BID. Adv: weight bearing exercise, calcium/vit D supplementation. F/U 2 weeks. | Your medicines: (1) albuterol inhaler 2 puffs every 4-6 hours as needed [rescue inhaler for breathing]. (2) metformin 500mg twice daily with meals [blood sugar medicine]. Advice: do weight-bearing exercises (walking, light weights) and take calcium and vitamin D for bone strength. Come back for a check-up in 2 weeks. | Pulmonology | Prescription | medium |
207 | 38 y/o F with PMH of SLE, h/o CVA, osteoporosis, OSA on CPAP, admitted for acute kidney injury. Creatinine rose sharply from baseline. Managed per protocol with improvement. Wound care: daily dressing changes with wet-to-dry gauze. D/C on timolol 0.5% OU BID, lisinopril 10mg daily, lisinopril 20mg daily. F/U surgery in... | A 38-year-old woman with a history of lupus, history of stroke, weak bones [osteoporosis], and sleep apnea [uses a breathing machine at night] was admitted for sudden worsening of kidney function. Kidney waste products rose sharply from baseline. They were treated according to standard guidelines and improved. Change t... | Nephrology | Discharge Summary | high |
208 | 66 y/o F with PMH of PPM in situ, A-fib, HLD, ESRD on HD, admitted for upper GI bleeding. Hematemesis noted. EGD showed bleeding ulcer. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on metformin 1000mg BID, Eliquis 5mg BID, timolol 0.5% OU BID, Dulcolax 10mg QHS PRN, ibuprofen 400mg Q6H PR... | A 66-year-old woman with a history of implanted pacemaker, irregular heartbeat [atrial fibrillation], high cholesterol, and kidney failure requiring dialysis was admitted for bleeding from the stomach or food pipe. Hematemesis noted. EGD showed bleeding ulcer. They were treated according to standard guidelines and impr... | Gastroenterology | Discharge Summary | high |
209 | 90 y/o F with PMH of ICD in situ, DM2, s/p THR, DM1, admitted for fall with hip fracture. X-ray confirmed femoral neck fracture. Orthopedics consulted. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on rosuvastatin 10mg QHS, warfarin 5mg daily, prednisone taper. F/U hemat... | A 90-year-old woman with a history of implanted heart defibrillator, type 2 diabetes, prior hip replacement, 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. Use the breathing exer... | Orthopedics | Discharge Summary | high |
210 | 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 |
211 | CXR PA: ET tube 3cm above carina. Patchy bilateral infiltrates. Cardiomegaly with CTR >0.5. Sternotomy wires intact. | Chest X-ray results: The breathing tube is in good position. There are scattered cloudy patches in both lungs suggesting infection or inflammation. The heart appears larger than normal. The wires from prior heart surgery are intact. | Pulmonology | Radiology Report | high |
212 | Rx: Tab hydroxychloroquine 200mg BID. Tab potassium chloride 20mEq daily. Tab omeprazole 20mg AC breakfast. Tab metoprolol succinate 50mg daily. Adv: elevate affected limb, compression stockings Adv: DASH diet, daily BP monitoring. F/U 1 week with CBC, CMP. | Your medicines: (1) hydroxychloroquine 200mg twice daily [immune-modulating medicine — eye exams needed]. (2) potassium supplement 20mEq once daily [replaces potassium lost from water pills]. (3) omeprazole 20mg before breakfast [acid-reducing medicine]. (4) metoprolol 50mg once daily [heart rate and blood pressure med... | Cardiology | Prescription | high |
213 | Doxycycline 100mg BID x 14 days with water; stay upright 30 min; avoid sun. | Take this antibiotic twice daily for 14 days with plenty of water, stay upright after doses, and use sun protection. | Infectious Disease | Medication Instruction | high |
214 | Rx: Tab ciprofloxacin 500mg BID x 5 days. Tab ASA 81mg daily. Adv: fall precautions, home safety evaluation Adv: high fiber diet, adequate hydration. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT. | Your medicines: (1) ciprofloxacin 500mg twice daily for 5 days [antibiotic — avoid dairy within 2 hours]. (2) baby aspirin 81mg once daily [prevents blood clots]. Advice: take steps to prevent falls — remove loose rugs, install grab bars, use night lights Advice: eat plenty of fiber (fruits, vegetables, whole grains) a... | Cardiology | Prescription | medium |
215 | Thyroid panel: TSH 14.83 (H), Free T4 2.9. | Your thyroid test results: TSH is elevated at 14.83 (normal 0.4-4.5), meaning your thyroid is underactive [hypothyroidism]. Free T4 is borderline — confirming the thyroid is not producing enough hormone. | Endocrinology | Lab Result | high |
216 | 46 y/o M with PMH of CKD Stage 3, cirrhosis, anemia, s/p THR, admitted for small bowel obstruction. CT showed dilated loops of bowel with transition point. Managed per protocol with improvement. Smoking cessation counseling provided. D/C on carvedilol 12.5mg BID, lisinopril 20mg daily. F/U nephrology in 5 days. | A 46-year-old man with a history of moderate kidney disease, liver scarring [cirrhosis], low blood count [anemia], and prior hip replacement was admitted for a blockage in the small intestine. CT scan showed dilated loops of bowel with transition point. They were treated according to standard guidelines and improved. S... | General Surgery | Discharge Summary | high |
217 | 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 |
218 | 61 y/o F with PMH of A-fib, s/p THR, admitted for appendicitis. CT confirmed. Taken to OR for laparoscopic appendectomy. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on latanoprost 0.005% OU QHS, rosuvastatin 10mg QHS, furosemide 40mg BID, Dulcolax 10mg QHS PRN. F/U nephrology ... | A 61-year-old woman with a history of irregular heartbeat [atrial fibrillation], and prior hip replacement was admitted for inflammation of the appendix. CT confirmed. Taken to OR for laparoscopic appendectomy. They were treated according to standard guidelines and improved. Write down your blood sugar readings in a lo... | General Surgery | Discharge Summary | high |
219 | Rx: Humalog per SSI. Tab clopidogrel 75mg daily. Tab sertraline 50mg daily. Tab ondansetron 4mg Q8H PRN N/V. Tab pregabalin 75mg BID. Avoid grapefruit juice Adv: smoking cessation, pulmonary rehab. F/U 4 weeks with TSH, Free T4. | Your medicines: (1) Humalog insulin before meals as directed [fast-acting insulin]. (2) Plavix (clopidogrel) 75mg once daily [blood thinner]. (3) sertraline 50mg once daily [antidepressant/anxiety medicine]. (4) ondansetron (Zofran) 4mg every 8 hours as needed [anti-nausea medicine]. (5) pregabalin 75mg twice daily [ne... | Cardiology | Prescription | high |
220 | Rx: Tab losartan 50mg daily. Tab escitalopram 10mg daily. Tab metformin 1000mg BID. Tab pregabalin 75mg BID. Tab furosemide 40mg BID. Avoid NSAIDs Adv: DASH diet, daily BP monitoring. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT. | Your medicines: (1) losartan 50mg once daily [blood pressure medicine]. (2) escitalopram 10mg once daily [antidepressant/anxiety medicine]. (3) metformin 1000mg twice daily with meals [blood sugar medicine]. (4) pregabalin 75mg twice daily [nerve pain medicine]. (5) furosemide (Lasix) 40mg twice daily [water pill]. Do ... | Cardiology | Prescription | high |
221 | 22 y/o F with PMH of HTN, HLD, asthma, CKD Stage 3, admitted for lower GI bleeding. Bright red blood per rectum. Hemoglobin dropping. Managed per protocol with improvement. Strict I&O, daily weights. D/C on hydroxychloroquine 200mg BID, escitalopram 10mg daily, acetaminophen 650mg Q6H PRN, methotrexate 15mg weekly. F/U... | A 22-year-old woman with a history of high blood pressure, high cholesterol, asthma, and moderate kidney disease was admitted for bleeding from the large intestine. Bright red blood per rectum. Hemoglobin dropping. They were treated according to standard guidelines and improved. Track how much you drink and urinate. We... | Gastroenterology | Discharge Summary | high |
222 | 84 y/o F presenting to ED with substernal CP radiating to L arm x 1hr, diaphoresis. Vitals: BP 165/95, HR 92, RR 18, O2 98%. ECG: ST elevation V1-V4. Troponin 2.1 (H). Dx: STEMI. Cath lab activated. ASA 325mg, Plavix 600mg, heparin bolus. Emergent PCI. | A 84-year-old woman came to the emergency room with crushing chest pain spreading to the left arm for 1 hour with heavy sweating. Vital signs: blood pressure elevated, heart rate slightly fast, breathing normal, oxygen normal. Heart test (ECG) showed a heart attack pattern. Blood test confirmed heart muscle damage. Dia... | Emergency Medicine | Clinical Note | high |
223 | 58 y/o M with PMH of hypothyroidism, asthma, HFrEF (EF 30%), h/o TIA, admitted for acute pancreatitis. Lipase markedly elevated. CT showed peripancreatic inflammation. Managed per protocol with improvement. Smoking cessation counseling provided. D/C on amlodipine 5mg daily, azithromycin 500mg day 1 then 250mg x 4 days.... | A 58-year-old man with a history of underactive thyroid, asthma, heart failure with weak pumping (30%), and history of mini-stroke 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 |
224 | Thyroid panel: TSH 2.6 (N), Free T4 0.5. | Your thyroid test results: TSH is normal at 2.6. Free T4 is normal — your thyroid function is balanced. | Endocrinology | Lab Result | medium |
225 | LFTs: AST 293 (H), ALT 358 (H), ALP 275, T.Bili 2.0 (H), Albumin 1.6. | Your liver blood test results: Liver enzymes (AST 293, ALT 358) are severely elevated, indicating significant liver damage (normal is under 40). Bilirubin is mildly elevated at 2.0. Albumin is low at 1.6 (normal 3.5-5.5), suggesting the liver is struggling to make important proteins. | Gastroenterology | Lab Result | high |
226 | 60 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 60-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 |
227 | Rx: Tab sertraline 50mg daily. Tab amlodipine 5mg daily. Tab warfarin 5mg daily. Adv: weight bearing exercise, calcium/vit D supplementation Adv: DASH diet, daily BP monitoring. F/U 2 weeks with INR. | Your medicines: (1) sertraline 50mg once daily [antidepressant/anxiety medicine]. (2) amlodipine 5mg once daily [blood pressure medicine]. (3) 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 ... | Cardiology | Prescription | medium |
228 | 25 y/o F with PMH of DVT/PE on warfarin, h/o CVA, anxiety, obesity (BMI 38), admitted for GI bleeding. Hemoglobin dropped. Required blood transfusion. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on losartan 50mg daily, potassium chloride 20mEq daily, lisinopril 20mg daily, metformin 500m... | A 25-year-old woman with a history of blood clots [on blood thinner warfarin], history of stroke, anxiety, and obesity was admitted for bleeding in the digestive tract. Blood count dropped. Required blood transfusion. They were treated according to standard guidelines and improved. Be careful to prevent falls. Physical... | Gastroenterology | Discharge Summary | high |
229 | CXR PA: Widened mediastinum. Sternotomy wires intact. Elevated left hemidiaphragm. Osseous structures intact. Moderate right pleural effusion. | Chest X-ray results: The space between the lungs appears wider than normal, which needs further evaluation. The wires from prior heart surgery are intact. The left side of the breathing muscle [diaphragm] is sitting higher than normal. The bones look normal with no fractures. There is a moderate amount of fluid around ... | Pulmonology | Radiology Report | high |
230 | Rx: Tab calcium + vitamin D 600/400 daily. Tab timolol 0.5% OU BID. Tab methotrexate 15mg weekly. Adv: high fiber diet, adequate hydration. F/U 6 weeks with LFTs. | Your medicines: (1) calcium plus vitamin D once daily [bone strengthening]. (2) timolol eye drops in both eyes twice daily [lowers eye pressure for glaucoma]. (3) methotrexate 15mg once weekly [immune-suppressing medicine for arthritis — requires monitoring]. Advice: eat plenty of fiber (fruits, vegetables, whole grain... | Rheumatology | Prescription | medium |
231 | 82 y/o M with PMH of CKD Stage 4, OA, HFpEF, admitted for acute stroke (CVA). CT showed acute ischemic infarct. tPA administered. Managed per protocol with improvement. Seizure precautions, do not drive x 6 months. D/C on empagliflozin 10mg daily, metformin 1000mg BID, ciprofloxacin 500mg BID x 5 days, potassium chlori... | A 82-year-old man with a history of advanced kidney disease, 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 treated according to standard guidelines ... | Neurology | Discharge Summary | high |
232 | Warfarin 5mg PO daily. INR goal 2.0-3.0. Avoid major diet changes in vitamin K. Report bleeding. | Take warfarin daily. Blood tests keep clotting in a safe range. Keep vitamin K intake steady and call your doctor for unusual bleeding. | Hematology | Medication Instruction | low |
233 | Rx: Tab hydroxychloroquine 200mg BID. Tab acetaminophen 650mg Q6H PRN. Adv: elevate affected limb, compression stockings. F/U 1 week with wound check. | Your medicines: (1) hydroxychloroquine 200mg twice daily [immune-modulating medicine — eye exams needed]. (2) Tylenol (acetaminophen) 650mg every 6 hours as needed [do not exceed 3000mg/day]. Advice: keep the affected leg elevated when resting and wear compression stockings. Come back in 1 week to have the wound checke... | Rheumatology | Prescription | medium |
234 | 33 y/o F with PMH of asthma, ESRD on HD, HLD, admitted for DKA. Blood sugar >500. pH 7.1. Anion gap elevated. Managed per protocol with improvement. BRAT diet x 48hrs, advance as tolerated. D/C on Augmentin 875/125 BID x 7 days, furosemide 40mg daily, rosuvastatin 10mg QHS, amlodipine 5mg daily, Xarelto 20mg daily with... | A 33-year-old woman with a history of asthma, kidney failure requiring dialysis, and high cholesterol was admitted for diabetic ketoacidosis [dangerously high blood sugar with acid buildup]. Blood sugar >500. blood became dangerously acidic. Anion gap elevated. They were treated according to standard guidelines and imp... | Endocrinology | Discharge Summary | high |
235 | Rx: Tab ASA 81mg daily. Tab furosemide 40mg daily. Tab azithromycin 500mg day 1 then 250mg x 4 days. Humalog per SSI. Avoid grapefruit juice. F/U 2 weeks with INR. | Your medicines: (1) baby aspirin 81mg once daily [prevents blood clots]. (2) furosemide (Lasix) 40mg once daily [water pill to remove extra fluid]. (3) azithromycin: 500mg on day 1, then 250mg for the next 4 days [antibiotic]. (4) Humalog insulin before meals as directed [fast-acting insulin]. Do not drink grapefruit j... | Cardiology | Prescription | high |
236 | 73 y/o F with PMH of s/p THR, s/p CABG, admitted for pneumonia. CXR confirmed infiltrate. Started on IV antibiotics. Managed per protocol with improvement. Elevate R leg above heart level when resting. D/C on hydroxychloroquine 200mg BID, Lantus 20U QHS, ondansetron 4mg Q8H PRN N/V, lisinopril 10mg daily. F/U GI in 1 w... | A 73-year-old woman with a history of prior hip replacement, and prior heart bypass surgery was admitted for a lung infection. CXR confirmed infiltrate. Started on IV antibiotics. They were treated according to standard guidelines and improved. When resting, prop your right leg up on pillows so it is higher than your h... | Pulmonology | Discharge Summary | high |
237 | 84 y/o M with PMH of s/p TKR, Parkinson's disease, osteoporosis, GERD, admitted for NSTEMI. Troponin elevated confirming heart muscle damage. Managed per protocol with improvement. Seizure precautions, do not drive x 6 months. D/C on Eliquis 5mg BID, calcium + vitamin D 600/400 daily, atorvastatin 80mg QHS, furosemide ... | A 84-year-old man with a history of prior knee replacement, Parkinson's disease, weak bones [osteoporosis], and acid reflux 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 guide... | Cardiology | Discharge Summary | high |
238 | 38 y/o F with PMH of h/o TIA, Parkinson's disease, admitted for upper GI bleeding. Hematemesis noted. EGD showed bleeding ulcer. Managed per protocol with improvement. Head injury precautions x 48hrs. D/C on pantoprazole 40mg AC breakfast, omeprazole 20mg AC breakfast, ibuprofen 400mg Q6H PRN with food. F/U hematology ... | A 38-year-old woman with a history of history of mini-stroke, and Parkinson's 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. Watch for: worsening headache, vomiting, confusion, unequal pupils... | Gastroenterology | Discharge Summary | high |
239 | 45 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 45-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 |
240 | LFTs: AST 115 (H), ALT 420 (H), ALP 65, T.Bili 7.3 (H), Albumin 4.8. | Your liver blood test results: Liver enzymes (AST 115, ALT 420) are severely elevated, indicating significant liver damage (normal is under 40). Bilirubin is high at 7.3 (normal under 1.2) — may cause yellowing of skin and eyes [jaundice]. Albumin is normal at 4.8. | Gastroenterology | Lab Result | high |
241 | Rx: Tab calcium + vitamin D 600/400 daily. prednisone taper. Tab metformin 500mg BID. Tab amlodipine 10mg daily. Tab lisinopril 20mg daily. Adv: high fiber diet, adequate hydration Adv: elevate affected limb, compression stockings. F/U 2 weeks with INR. | Your medicines: (1) calcium plus vitamin D once daily [bone strengthening]. (2) prednisone steroid — dose gradually decreases as directed [do not stop suddenly]. (3) metformin 500mg twice daily with meals [blood sugar medicine]. (4) amlodipine 10mg once daily [blood pressure medicine]. (5) lisinopril 20mg once daily [b... | Cardiology | Prescription | high |
242 | CT Head without contrast: No mass effect. Acute ischemic infarct in R MCA territory. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. | CT scan of the head results: There are no tumors or masses pushing on the brain. There is a new stroke affecting the right side of the brain, in the area supplied by the middle cerebral artery. There are aging-related changes in the brain's white matter from reduced blood flow to small vessels over time. | Neurology | Radiology Report | high |
243 | US Abdomen: GB sludge, no stones. Left kidney 8cm, cortical thinning consistent with CKD. Spleen 11cm, normal. Ascites moderate amount. No focal hepatic lesion. Liver 18cm, diffusely echogenic consistent with hepatic steatosis. | Abdominal ultrasound results: The gallbladder contains thickened bile [sludge] but no stones. Left kidney is small with thin outer layer, consistent with chronic kidney disease. The spleen is a normal size. There is a moderate amount of fluid in the belly [ascites]. No tumors or masses were found in the liver. The live... | Gastroenterology | Radiology Report | high |
244 | CXR PA: Hyperinflated lungs consistent with COPD. Sternotomy wires intact. Widened mediastinum. | Chest X-ray results: The lungs appear over-inflated, which is typical of chronic lung disease [COPD/emphysema]. The wires from prior heart surgery are intact. The space between the lungs appears wider than normal, which needs further evaluation. | Pulmonology | Radiology Report | high |
245 | CXR PA: No cardiomegaly. Cardiomegaly with CTR >0.5. Bilateral hilar lymphadenopathy. Moderate right pleural effusion. | Chest X-ray results: The heart is a normal size. The heart appears larger than normal. There are enlarged lymph nodes at the root of both lungs, which needs further evaluation. There is a moderate amount of fluid around the right lung. | Pulmonology | Radiology Report | high |
246 | 33 y/o M with PMH of gout, obesity (BMI 38), h/o CVA, anemia, HTN, admitted for STEMI. ECG showed ST elevation. Troponin markedly elevated. Managed per protocol with improvement. Head injury precautions x 48hrs. D/C on calcium + vitamin D 600/400 daily, Xarelto 20mg daily with dinner, metoprolol 25mg BID. F/U neurology... | A 33-year-old man with a history of gout, obesity, history of stroke, low blood count [anemia], and high blood pressure 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. Watch for: ... | Cardiology | Discharge Summary | high |
247 | 84 y/o M with PMH of BPH, HTN, admitted for HHS. Blood sugar >800. Severe dehydration. Managed per protocol with improvement. Low potassium diet. D/C on spironolactone 25mg daily, latanoprost 0.005% OU QHS. F/U INR check in 3 days. | A 84-year-old man with a history of enlarged prostate, and high blood pressure was admitted for hyperosmolar hyperglycemic state [extremely high blood sugar]. Blood sugar >800. Severe dehydration. They were treated according to standard guidelines and improved. Avoid high-potassium foods: bananas, oranges, potatoes, to... | Endocrinology | Discharge Summary | high |
248 | Rx: Tab timolol 0.5% OU BID. Tab metoprolol 25mg BID. Avoid grapefruit juice. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT. | Your medicines: (1) timolol eye drops in both eyes twice daily [lowers eye pressure for glaucoma]. (2) metoprolol 25mg twice daily [slows heart rate and lowers blood pressure]. Do not drink grapefruit juice as it interferes with this medication. Come back in 2 weeks with blood tests for: fasting blood sugar [FBS], 3-mo... | Cardiology | Prescription | medium |
249 | Amiodarone load per protocol then maintenance; monitor thyroid and liver tests. | Heart rhythm medicine starts with a supervised loading phase then a lower daily dose. Blood tests monitor thyroid and liver. | Cardiology | Medication Instruction | high |
250 | CT Head without contrast: No acute intracranial hemorrhage. No mass effect. No midline shift. | CT scan of the head results: There is no bleeding in the brain. There are no tumors or masses pushing on the brain. The brain is centered normally. | Neurology | Radiology Report | high |
251 | 49 y/o M with PMH of s/p TKR, OA, admitted for pyelonephritis. UA showed infection. Flank pain and fever. IV antibiotics started. Managed per protocol with improvement. Compression stockings when ambulating. D/C on prednisone taper, tramadol 50mg Q6H PRN pain. F/U orthopedics in 6 weeks with X-ray. | A 49-year-old man with a history of prior knee replacement, and arthritis [osteoarthritis] was admitted for a serious kidney infection. Urine test confirmed infection. Flank pain and fever. IV antibiotics started. They were treated according to standard guidelines and improved. Wear compression stockings on your legs w... | Urology | Discharge Summary | high |
252 | Rx: Tab lisinopril 10mg daily. Tab furosemide 40mg BID. Tab Dulcolax 10mg QHS PRN. Tab ondansetron 4mg Q8H PRN N/V. Adv: elevate affected limb, compression stockings Adv: low salt low sugar diet, regular exercise. F/U 1 week with wound check. | Your medicines: (1) lisinopril 10mg once daily [blood pressure medicine that also protects kidneys]. (2) furosemide (Lasix) 40mg twice daily [water pill]. (3) Dulcolax 10mg at bedtime as needed [for constipation]. (4) ondansetron (Zofran) 4mg every 8 hours as needed [anti-nausea medicine]. Advice: keep the affected leg... | Cardiology | Prescription | high |
253 | 64 y/o M with PMH of depression, HLD, OSA on CPAP, admitted for hypertensive urgency. BP 210/120. IV medications started to lower gradually. Managed per protocol with improvement. Daily weights, 1.5L fluid restriction, low sodium diet. D/C on calcium + vitamin D 600/400 daily, clopidogrel 75mg daily, carvedilol 12.5mg ... | A 64-year-old man with a history of depression, high cholesterol, and sleep apnea [uses a breathing machine at night] was admitted for dangerously high blood pressure. BP 210/120. IV medications started to lower gradually. They were treated according to standard guidelines and improved. Weigh yourself every morning bef... | Cardiology | Discharge Summary | high |
254 | Rx: albuterol MDI 2 puffs Q4-6H PRN. Tab potassium chloride 20mEq daily. Tab ibuprofen 400mg Q6H PRN with food. Tab carvedilol 12.5mg BID. Adv: high fiber diet, adequate hydration Adv: weight bearing exercise, calcium/vit D supplementation. F/U 1 month with repeat imaging. | Your medicines: (1) albuterol inhaler 2 puffs every 4-6 hours as needed [rescue inhaler for breathing]. (2) potassium supplement 20mEq once daily [replaces potassium lost from water pills]. (3) ibuprofen 400mg every 6 hours as needed with food [anti-inflammatory pain reliever]. (4) carvedilol 12.5mg twice daily [heart ... | General | Prescription | high |
255 | 38 y/o F with PMH of s/p THR, HLD, s/p TKR, PAD, DVT/PE on warfarin, admitted for small bowel obstruction. CT showed dilated loops of bowel with transition point. Managed per protocol with improvement. Seizure precautions, do not drive x 6 months. D/C on clopidogrel 75mg daily, furosemide 40mg daily. F/U cardiology in ... | A 38-year-old woman with a history of prior hip replacement, high cholesterol, prior knee replacement, poor blood flow in the legs [peripheral artery disease], and blood clots [on blood thinner warfarin] was admitted for a blockage in the small intestine. CT scan showed dilated loops of bowel with transition point. The... | General Surgery | Discharge Summary | high |
256 | CT Head without contrast: Paranasal sinuses clear. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. Chronic lacunar infarcts in bilateral basal ganglia. | CT scan of the head results: 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 are signs of small old strokes in the deep parts of the brain. | Neurology | Radiology Report | high |
257 | Rx: Tab metoprolol 25mg BID. Tab empagliflozin 10mg daily. Avoid NSAIDs. F/U INR in 3 days. | Your medicines: (1) metoprolol 25mg twice daily [slows heart rate and lowers blood pressure]. (2) empagliflozin 10mg once daily [blood sugar medicine that also protects heart and kidneys]. Do not take anti-inflammatory pain medicines like ibuprofen (Advil) or naproxen (Aleve) as they can harm your kidneys. Come back in... | Cardiology | Prescription | medium |
258 | CXR PA: Port-a-cath in appropriate position. Widened mediastinum. Osseous structures intact. | Chest X-ray results: The implanted medication port is in the correct position. The space between the lungs appears wider than normal, which needs further evaluation. The bones look normal with no fractures. | Pulmonology | Radiology Report | high |
259 | Rx: Tab ferrous sulfate 325mg BID. Tab levothyroxine 75mcg daily on empty stomach. Adv: smoking cessation, pulmonary rehab Adv: SMBG BID, diabetic diet. F/U 2 weeks. | Your medicines: (1) iron supplement 325mg twice daily [for low blood count — take with vitamin C]. (2) levothyroxine 75mcg on empty stomach 30 min before breakfast [thyroid medicine]. Advice: stop smoking (ask about nicotine patches or gum) and attend lung rehabilitation program Advice: check your blood sugar twice dai... | Endocrinology | Prescription | medium |
260 | CXR PA: Pacemaker leads in appropriate position. Small left pleural effusion. No pneumothorax. Bilateral hilar lymphadenopathy. Hyperinflated lungs consistent with COPD. | Chest X-ray results: The pacemaker wires are in the correct position. There is a small amount of fluid around the left lung. There is no collapsed lung. There are enlarged lymph nodes at the root of both lungs, which needs further evaluation. The lungs appear over-inflated, which is typical of chronic lung disease [COP... | Pulmonology | Radiology Report | high |
261 | HbA1c: 6.9% (H). FBS: 139 mg/dL (H). | Your diabetes blood test results: HbA1c is 6.9%, which is at the diabetes target. Your diabetes is reasonably well controlled. Fasting blood sugar was 139, which is high (normal is 70-100). Continue current diabetes treatment plan. | Endocrinology | Lab Result | high |
262 | 86 y/o M with PMH of depression, A-fib, COPD, CAD, admitted for lower GI bleeding. Bright red blood per rectum. Hemoglobin dropping. Managed per protocol with improvement. Low potassium diet. D/C on albuterol MDI 2 puffs Q4-6H PRN, glipizide 5mg BID AC. F/U neurology in 2 weeks. | A 86-year-old man with a history of depression, irregular heartbeat [atrial fibrillation], chronic lung disease, and coronary artery disease [heart artery blockages] was admitted for bleeding from the large intestine. Bright red blood per rectum. Hemoglobin dropping. They were treated according to standard guidelines a... | Gastroenterology | Discharge Summary | high |
263 | CT Head without contrast: Chronic lacunar infarcts in bilateral basal ganglia. Paranasal sinuses clear. No midline shift. Subarachnoid hemorrhage in bilateral sylvian fissures. Mild generalized cerebral atrophy appropriate for age. | CT scan of the head results: There are signs of small old strokes in the deep parts of the brain. The sinuses are clear with no infection. The brain is centered normally. There is bleeding around the brain surface, particularly in the grooves on both sides. There is mild brain shrinkage, which is normal for your age. | Neurology | Radiology Report | high |
264 | Procedure: Colonoscopy with polypectomy. Pt 31 y/o M. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes colon exam with removal of polyps for a 31-year-old man. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | Gastroenterology | Procedure Note | high |
265 | US Abdomen: Simple renal cysts bilaterally. No focal hepatic lesion. Pancreas unremarkable. GB sludge, no stones. CBD 5mm, not dilated. GB wall thickening with stones, positive Murphy's sign. | Abdominal ultrasound results: Both kidneys have harmless fluid-filled cysts. No tumors or masses were found in the liver. The pancreas looks normal. The gallbladder contains thickened bile [sludge] but no stones. The bile duct is normal size [not blocked]. The gallbladder wall is thickened and gallstones are present — ... | Gastroenterology | Radiology Report | high |
266 | Procedure: ORIF L distal radius. 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 surgery to fix a wrist fracture with plate and screws 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. | Orthopedics | Procedure Note | high |
267 | 79 y/o M with PMH of DVT/PE on warfarin, h/o CVA, GERD, admitted for lower GI bleeding. Bright red blood per rectum. Hemoglobin dropping. Managed per protocol with improvement. Diabetic diet, SMBG BID. D/C on pregabalin 75mg BID, methotrexate 15mg weekly, spironolactone 25mg daily, ASA 81mg daily, escitalopram 10mg dai... | A 79-year-old man with a history of blood clots [on blood thinner warfarin], history of stroke, and acid reflux was admitted for bleeding from the large intestine. Bright red blood per rectum. Hemoglobin dropping. They were treated according to standard guidelines and improved. Follow a diabetes-friendly diet (limit sw... | Gastroenterology | Discharge Summary | high |
268 | HbA1c: 11.1% (H). FBS: 223 mg/dL (H). | Your diabetes blood test results: HbA1c is 11.1%, which is very high, meaning blood sugar has been dangerously uncontrolled (target is under 7%). Fasting blood sugar was 223, which is high (normal is 70-100). Urgent medication adjustment needed. Very high risk of diabetes complications at this level. | Endocrinology | Lab Result | high |
269 | 22 y/o M with PMH of asthma, hypothyroidism, admitted for atrial fibrillation with RVR. HR 150s. Diltiazem drip started for rate control. Managed per protocol with improvement. Strict I&O, daily weights. D/C on Spiriva 18mcg daily, calcium + vitamin D 600/400 daily, Augmentin 875/125 BID x 7 days. F/U orthopedics in 6 ... | A 22-year-old man with a history of asthma, and underactive thyroid was admitted for irregular heartbeat with dangerously fast rate. HR 150s. Diltiazem drip started for rate control. They were treated according to standard guidelines and improved. Track how much you drink and urinate. Weigh yourself every morning.. Med... | Cardiology | Discharge Summary | high |
270 | Procedure: EGD with biopsy. Pt 56 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 upper endoscopy with small tissue samples taken for a 56-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 |
271 | 34 y/o F with PMH of cirrhosis, asthma, BPH, CKD Stage 4, h/o CVA, admitted for acute CHF exacerbation. BNP elevated. CXR showed pulmonary edema. Managed per protocol with improvement. Seizure precautions, do not drive x 6 months. D/C on amlodipine 5mg daily, omeprazole 20mg AC breakfast. F/U surgery in 10 days. | A 34-year-old woman with a history of liver scarring [cirrhosis], asthma, enlarged prostate, advanced kidney disease, and history of stroke was admitted for worsening heart failure with fluid buildup. BNP elevated. Chest X-ray showed pulmonary edema. They were treated according to standard guidelines and improved. Take... | Cardiology | Discharge Summary | high |
272 | US Abdomen: CBD 5mm, not dilated. GB wall thickening with stones, positive Murphy's sign. Pancreas unremarkable. Simple renal cysts bilaterally. Ascites moderate amount. | Abdominal ultrasound results: The bile duct is normal size [not blocked]. The gallbladder wall is thickened and gallstones are present — pressing on the gallbladder area caused pain [positive Murphy's sign], suggesting infection. The pancreas looks normal. Both kidneys have harmless fluid-filled cysts. There is a moder... | Gastroenterology | Radiology Report | high |
273 | Lipid panel: TC 271, LDL 68, HDL 59, TG 52. | Your cholesterol results: Total cholesterol is 271. LDL (bad cholesterol) is at goal (68). HDL (good cholesterol) is good at 59. Triglycerides are normal at 52. | Cardiology | Lab Result | medium |
274 | CXR PA: Right lower lobe consolidation. Cardiomegaly with CTR >0.5. No cardiomegaly. | Chest X-ray results: There is an area in the lower right lung that appears infected, suggesting pneumonia. The heart appears larger than normal. The heart is a normal size. | Pulmonology | Radiology Report | high |
275 | 39 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 39-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 |
276 | MRI Lumbar Spine: No compression fracture. Multilevel degenerative disc disease. | MRI of the lower back results: No bones are broken or collapsed. Multiple discs in the spine are showing wear and aging. | Orthopedics | Radiology Report | high |
277 | HbA1c: 5.9% (H). FBS: 258 mg/dL (H). | Your diabetes blood test results: HbA1c is 5.9%, 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 258, which is high (normal is 70-100). Lifestyle changes (diet, exercise, weight loss) can prevent progression to diabetes. | Endocrinology | Lab Result | high |
278 | 79 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 79-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 |
279 | 77 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 77-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 |
280 | HbA1c: 10.9% (H). FBS: 387 mg/dL (H). | Your diabetes blood test results: HbA1c is 10.9%, which is very high, meaning blood sugar has been dangerously uncontrolled (target is under 7%). Fasting blood sugar was 387, which is high (normal is 70-100). Urgent medication adjustment needed. Very high risk of diabetes complications at this level. | Endocrinology | Lab Result | high |
281 | Latanoprost OU QHS; remove contacts before drops; punctal occlusion 1 min. | Glaucoma drops at bedtime in both eyes; remove contacts before use and gently press inner corners for one minute. | Ophthalmology | Medication Instruction | medium |
282 | 90 y/o M with PMH of asthma, HLD, DVT/PE on warfarin, s/p THR, admitted for DKA. Blood sugar >500. pH 7.1. Anion gap elevated. Managed per protocol with improvement. BRAT diet x 48hrs, advance as tolerated. D/C on ciprofloxacin 500mg BID x 5 days, Dulcolax 10mg QHS PRN, amlodipine 5mg daily. F/U surgery in 10 days. | A 90-year-old man with a history of asthma, high cholesterol, blood clots [on blood thinner warfarin], and prior hip replacement was admitted for diabetic ketoacidosis [dangerously high blood sugar with acid buildup]. Blood sugar >500. blood became dangerously acidic. Anion gap elevated. They were treated according to ... | Endocrinology | Discharge Summary | high |
283 | PATH: Shave bx: actinic keratosis, suggest sunscreen and dermatology follow-up. | Pathology results in plain language: Sun-damaged spot on skin — precancerous change. Protect skin from sun and follow with skin doctor. | Dermatology | Pathology Report | high |
284 | Rx: Tab omeprazole 20mg AC breakfast. Tab furosemide 40mg BID. Tab metformin 1000mg BID. Adv: fall precautions, home safety evaluation. F/U INR in 3 days. | Your medicines: (1) omeprazole 20mg before breakfast [acid-reducing medicine]. (2) furosemide (Lasix) 40mg twice daily [water pill]. (3) metformin 1000mg twice daily with meals [blood sugar medicine]. Advice: take steps to prevent falls — remove loose rugs, install grab bars, use night lights. Come back in 3 days for a... | Cardiology | Prescription | medium |
285 | 23 y/o M with PMH of h/o CVA, BPH, admitted for DKA. Blood sugar >500. pH 7.1. Anion gap elevated. Managed per protocol with improvement. Low potassium diet. D/C on metformin 1000mg BID, lisinopril 10mg daily, Spiriva 18mcg daily. F/U orthopedics in 6 weeks with X-ray. | A 23-year-old man with a history of history of stroke, and enlarged prostate was admitted for diabetic ketoacidosis [dangerously high blood sugar with acid buildup]. Blood sugar >500. blood became dangerously acidic. Anion gap elevated. They were treated according to standard guidelines and improved. Avoid high-potassi... | Endocrinology | Discharge Summary | high |
286 | BMP: Na 138 (N), K 6.2 (H), BUN 22, Cr 2.9 (H), Glucose 164. | Your blood chemistry results: Sodium is normal at 138. Potassium is dangerously high at 6.2 (normal 3.5-5.0) — this can affect your heart and needs immediate treatment. Creatinine is elevated at 2.9 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 164 (high). | Nephrology | Lab Result | high |
287 | CT Head without contrast: Subarachnoid hemorrhage in bilateral sylvian fissures. 4cm right subdural hematoma with 5mm midline shift. Chronic lacunar infarcts in bilateral basal ganglia. Mild generalized cerebral atrophy appropriate for age. | 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 are signs of small old strokes in the deep parts of ... | Neurology | Radiology Report | high |
288 | Procedure: ORIF L distal radius. Pt 39 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 surgery to fix a wrist fracture with plate and screws for a 39-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 |
289 | 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 |
290 | 65 y/o F with PMH of DM1, CKD Stage 3, h/o CVA, CKD Stage 4, PAD, admitted for alcohol withdrawal. CIWA protocol initiated. Lorazepam given as needed. Managed per protocol with improvement. Smoking cessation counseling provided. D/C on pregabalin 75mg BID, hydroxychloroquine 200mg BID, latanoprost 0.005% OU QHS, pantop... | A 65-year-old woman with a history of type 1 diabetes, moderate kidney disease, history of stroke, advanced kidney disease, and poor blood flow in the legs [peripheral artery disease] was admitted for withdrawal symptoms after stopping alcohol. CIWA protocol initiated. Lorazepam given as needed. They were treated accor... | Psychiatry | Discharge Summary | high |
291 | 39 y/o F with PMH of ICD in situ, HFrEF (EF 30%), BPH, admitted for pneumonia. CXR confirmed infiltrate. Started on IV antibiotics. Managed per protocol with improvement. Compression stockings when ambulating. D/C on lisinopril 20mg daily, ondansetron 4mg Q8H PRN N/V, clopidogrel 75mg daily, atorvastatin 80mg QHS. F/U ... | A 39-year-old woman with a history of implanted heart defibrillator, heart failure with weak pumping (30%), and enlarged prostate was admitted for a lung infection. CXR confirmed infiltrate. Started on IV antibiotics. They were treated according to standard guidelines and improved. Wear compression stockings on your le... | Pulmonology | Discharge Summary | high |
292 | CT Head without contrast: No acute intracranial hemorrhage. No midline shift. 4cm right subdural hematoma with 5mm midline shift. No mass effect. | CT scan of the head results: There is no bleeding in the brain. The brain is centered normally. 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 are no tumors or masses pushing on the brain. | Neurology | Radiology Report | high |
293 | 57 y/o F with PMH of CHF, DVT/PE on warfarin, depression, admitted for acute kidney injury. Creatinine rose sharply from baseline. Managed per protocol with improvement. Daily weights, 1.5L fluid restriction, low sodium diet. D/C on Xarelto 20mg daily with dinner, lisinopril 10mg daily, furosemide 40mg BID, sertraline ... | A 57-year-old woman with a history of heart failure, blood clots [on blood thinner warfarin], and depression was admitted for sudden worsening of kidney function. Kidney waste products rose sharply from baseline. They were treated according to standard guidelines and improved. Weigh yourself every morning before eating... | Nephrology | Discharge Summary | high |
294 | 70 y/o F presenting to ED with acute onset SOB, unable to speak in full sentences. Vitals: BP 168/92, HR 118, RR 28, O2 85% on RA. CXR: bilateral pleural effusions, pulmonary edema. BNP 2400. Dx: Acute decompensated CHF. IV furosemide 80mg, BiPAP, nitroglycerin drip. Admit CCU. | A 70-year-old woman came to the emergency room with sudden severe difficulty breathing, unable to finish sentences. Vital signs: blood pressure high, heart rate very fast, breathing very rapid, oxygen dangerously low at 85%. Chest X-ray showed fluid in both lungs. Heart failure blood test very high. Diagnosis: severe h... | Emergency Medicine | Clinical Note | high |
295 | Rx: Tab Xarelto 20mg daily with dinner. Tab furosemide 40mg BID. Adv: avoid alcohol, hepatotoxic drugs Adv: smoking cessation, pulmonary rehab. F/U 1 week with wound check. | Your medicines: (1) Xarelto 20mg once daily with dinner [blood thinner]. (2) furosemide (Lasix) 40mg twice daily [water pill]. Advice: do not drink alcohol and avoid medications that can harm the liver (including acetaminophen in excess) Advice: stop smoking (ask about nicotine patches or gum) and attend lung rehabilit... | Cardiology | Prescription | medium |
296 | Rx: Tab furosemide 40mg BID. Tab pregabalin 75mg BID. Tab Augmentin 875/125 BID x 7 days. Adv: low salt low sugar diet, regular exercise Adv: high fiber diet, adequate hydration. F/U 2 weeks with INR. | Your medicines: (1) furosemide (Lasix) 40mg twice daily [water pill]. (2) pregabalin 75mg twice daily [nerve pain medicine]. (3) Augmentin 875mg twice daily for 7 days [antibiotic]. Advice: eat less salt and sugar, and exercise at least 30 minutes most days Advice: eat plenty of fiber (fruits, vegetables, whole grains)... | Cardiology | Prescription | medium |
297 | 73 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 73-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 |
298 | Rx: Tab methotrexate 15mg weekly. Tab atorvastatin 40mg QHS. Tab empagliflozin 10mg daily. Tab ASA 81mg daily. Adv: SMBG BID, diabetic diet Adv: DASH diet, daily BP monitoring. F/U 2 weeks with INR. | Your medicines: (1) methotrexate 15mg once weekly [immune-suppressing medicine for arthritis — requires monitoring]. (2) atorvastatin 40mg at bedtime [cholesterol medicine]. (3) empagliflozin 10mg once daily [blood sugar medicine that also protects heart and kidneys]. (4) baby aspirin 81mg once daily [prevents blood cl... | Cardiology | Prescription | high |
299 | MRI Lumbar Spine: L5-S1 disc desiccation with mild bulge. Facet joint hypertrophy at L4-L5. Multilevel degenerative disc disease. L4-L5 disc herniation with moderate bilateral foraminal stenosis. | 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. The small joints in the spine at L4-L5 are enlarged from arthritis. Multiple discs in the spine are showing wear and aging. At the L4-L5 level, a disc has pushed outward [herniated]... | Orthopedics | Radiology Report | high |
300 | 81 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 81-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 |
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