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301
MRI Lumbar Spine: Central canal stenosis at L3-L4. L5-S1 disc desiccation with mild bulge. L4-L5 disc herniation with moderate bilateral foraminal stenosis. Multilevel degenerative disc disease.
MRI of the lower back results: The spinal canal is narrowed at L3-L4, which may be pressing on the nerves. At the L5-S1 level, the disc is dried out [worn] with a slight bulge, but not causing significant pressure. At the L4-L5 level, a disc has pushed outward [herniated] and is narrowing the nerve tunnels on both side...
Orthopedics
Radiology Report
high
302
36 y/o M with PMH of osteoporosis, h/o TIA, h/o CVA, admitted for NSTEMI. Troponin elevated confirming heart muscle damage. Managed per protocol with improvement. Daily weights, 1.5L fluid restriction, low sodium diet. D/C on amoxicillin 500mg TID x 10 days, empagliflozin 10mg daily, glipizide 5mg BID AC, spironolacton...
A 36-year-old man with a history of weak bones [osteoporosis], history of mini-stroke, and history of stroke 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 impro...
Cardiology
Discharge Summary
high
303
81 y/o F 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 81-year-old woman 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. ...
Emergency Medicine
Clinical Note
high
304
60 y/o M with PMH of OA, DM1, HLD, admitted for DVT. Ultrasound confirmed DVT. Anticoagulation started. Managed per protocol with improvement. Strict I&O, daily weights. D/C on potassium chloride 20mEq daily, atorvastatin 80mg QHS, azithromycin 500mg day 1 then 250mg x 4 days, ondansetron 4mg Q8H PRN N/V. F/U INR check...
A 60-year-old man with a history of arthritis [osteoarthritis], type 1 diabetes, and high cholesterol was admitted for a blood clot in the leg [deep vein thrombosis]. Ultrasound confirmed DVT. Anticoagulation started. They were treated according to standard guidelines and improved. Track how much you drink and urinate....
Hematology
Discharge Summary
high
305
BMP: Na 129 (L), K 6.0 (H), BUN 73, Cr 0.7 (N), Glucose 208.
Your blood chemistry results: Sodium is low at 129 (normal 136-145), meaning too much water in your body. Potassium is dangerously high at 6.0 (normal 3.5-5.0) — this can affect your heart and needs immediate treatment. Creatinine is normal at 0.7. Blood sugar is 208 (high).
Nephrology
Lab Result
high
306
Amiodarone load per protocol then maintenance; monitor thyroid and liver tests.
Heart rhythm medicine starts with a supervised loading phase then a lower daily dose. Blood tests monitor thyroid and liver.
Cardiology
Medication Instruction
medium
307
67 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 67-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
308
65 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 65-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
309
48 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 48-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
310
CXR PA: Osseous structures intact. Mild cardiomegaly. Pacemaker leads in appropriate position.
Chest X-ray results: The bones look normal with no fractures. The heart is slightly larger than normal. The pacemaker wires are in the correct position.
Pulmonology
Radiology Report
high
311
48 y/o F presenting to ED with RLQ pain x 12hrs, anorexia, low-grade fever. Vitals: BP 128/76, HR 96, T 100.8F. CT abdomen: 9mm dilated appendix with periappendiceal fat stranding, no perforation. Dx: Acute uncomplicated appendicitis. NPO, IV Zosyn. Surgery consulted for laparoscopic appendectomy. Admit surgery.
A 48-year-old woman came to the emergency room with pain in the lower right belly for 12 hours, loss of appetite, and mild fever. Vital signs: blood pressure normal, heart rate slightly fast, mild fever. CT scan showed the appendix is swollen (9mm, normal <6mm) with inflammation around it but no rupture. Diagnosis: app...
Emergency Medicine
Clinical Note
high
312
Thyroid panel: TSH 14.75 (H), Free T4 0.7.
Your thyroid test results: TSH is elevated at 14.75 (normal 0.4-4.5), meaning your thyroid is underactive [hypothyroidism]. Free T4 is low — confirming the thyroid is not producing enough hormone.
Endocrinology
Lab Result
high
313
MRI Lumbar Spine: C5-C6 disc herniation with cord compression. Conus medullaris at L1, normal. Facet joint hypertrophy at L4-L5. Multilevel degenerative disc disease.
MRI of the lower back results: At C5-C6 in the neck, a disc has pushed out and is pressing on the spinal cord — this is significant. The spinal cord ends at a normal level. The small joints in the spine at L4-L5 are enlarged from arthritis. Multiple discs in the spine are showing wear and aging.
Orthopedics
Radiology Report
high
314
Rx: Tab methotrexate 15mg weekly. Spiriva 18mcg daily. Tab losartan 50mg daily. Tab tramadol 50mg Q6H PRN pain. 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) Spiriva inhaler once daily [long-acting lung medicine]. (3) losartan 50mg once daily [blood pressure medicine]. (4) tramadol 50mg every 6 hours as needed for pain [may cause drowsiness — max 4/day]. ...
Cardiology
Prescription
high
315
CBC: WBC 21.6 (H), Hgb 13.0 (N), Plt 489 (H).
Your blood count results: White blood cells are 21.6 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is normal at 13.0. Platelets are 489, which is high — your blood may clot too easily.
Hematology
Lab Result
high
316
Levetiracetam 500mg BID; do not stop suddenly; report mood changes.
Anti-seizure medicine twice daily; taper only with clinician guidance; watch for mood side effects.
Neurology
Medication Instruction
medium
317
CXR PA: Port-a-cath in appropriate position. Bilateral hilar lymphadenopathy. Sternotomy wires intact. Pacemaker leads in appropriate position. ET tube 3cm above carina.
Chest X-ray results: The implanted medication port is in the correct position. There are enlarged lymph nodes at the root of both lungs, which needs further evaluation. The wires from prior heart surgery are intact. The pacemaker wires are in the correct position. The breathing tube is in good position.
Pulmonology
Radiology Report
high
318
CBC: WBC 6.7 (N), Hgb 16.6 (N), Plt 117 (L).
Your blood count results: White blood cells are 6.7 (normal). Hemoglobin is normal at 16.6. Platelets are 117, which is low — your blood may not clot properly, increasing bleeding risk.
Hematology
Lab Result
high
319
Thyroid panel: TSH 9.43 (H), Free T4 2.4.
Your thyroid test results: TSH is elevated at 9.43 (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
320
CBC: WBC 15.4 (H), Hgb 5.7 (L), Plt 473 (H).
Your blood count results: White blood cells are 15.4 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is low at 5.7, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 473, which is high — your blood may clot too easily.
Hematology
Lab Result
high
321
HbA1c: 6.2% (H). FBS: 102 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 102, which is high (normal is 70-100). Lifestyle changes (diet, exercise, weight loss) can prevent progression to diabetes.
Endocrinology
Lab Result
high
322
Procedure: ERCP with sphincterotomy. Pt 44 y/o M. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed.
This note describes procedure to open the bile duct using a scope for a 44-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
323
31 y/o M with PMH of h/o CVA, hypothyroidism, seizure disorder on Keppra, admitted for GI bleeding. Hemoglobin dropped. Required blood transfusion. Managed per protocol with improvement. Seizure precautions, do not drive x 6 months. D/C on Lantus 20U QHS, glipizide 5mg BID AC. F/U surgery in 10 days.
A 31-year-old man with a history of history of stroke, underactive thyroid, and seizure disorder [on Keppra] was admitted for bleeding in the digestive tract. Blood count dropped. Required blood transfusion. They were treated according to standard guidelines and improved. Take seizure safety measures (no baths alone, n...
Gastroenterology
Discharge Summary
high
324
Thyroid panel: TSH 6.48 (H), Free T4 0.8.
Your thyroid test results: TSH is elevated at 6.48 (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
325
US Abdomen: Pancreas unremarkable. Spleen 16cm, splenomegaly. Simple renal cysts bilaterally.
Abdominal ultrasound results: The pancreas looks normal. The spleen is enlarged [splenomegaly]. Both kidneys have harmless fluid-filled cysts.
Gastroenterology
Radiology Report
high
326
86 y/o F with PMH of s/p CABG, DM2, DM1, gout, admitted for alcohol withdrawal. CIWA protocol initiated. Lorazepam given as needed. Managed per protocol with improvement. Smoking cessation counseling provided. D/C on ASA 81mg daily, gabapentin 300mg TID. F/U neurology in 2 weeks.
A 86-year-old woman with a history of prior heart bypass surgery, type 2 diabetes, type 1 diabetes, and gout was admitted for withdrawal symptoms after stopping alcohol. CIWA protocol initiated. Lorazepam given as needed. They were treated according to standard guidelines and improved. Strongly encouraged to quit smoki...
Psychiatry
Discharge Summary
high
327
BMP: Na 137 (N), K 2.9 (L), BUN 82, Cr 1.5 (H), Glucose 394.
Your blood chemistry results: Sodium is normal at 137. Potassium is low at 2.9 — may cause muscle weakness and heart rhythm issues. Creatinine is mildly elevated at 1.5. Blood sugar is 394 (high).
Nephrology
Lab Result
high
328
89 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 89-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
329
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
330
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
331
Rx: Tab metformin 500mg BID. Humalog per SSI. Tab amoxicillin 500mg TID x 10 days. Avoid grapefruit juice. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT.
Your medicines: (1) metformin 500mg twice daily with meals [blood sugar medicine]. (2) Humalog insulin before meals as directed [fast-acting insulin]. (3) amoxicillin 500mg three times daily for 10 days [antibiotic — complete full course]. Do not drink grapefruit juice as it interferes with this medication. Come back i...
Endocrinology
Prescription
medium
332
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
333
Delivery Note: G?P? at 37+3 weeks. Primary low-transverse C-section. Live female infant. APGAR 8/9. 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 8/9. Bleeding was normal. Mother did well after delivery.
Obstetrics
Delivery Note
high
334
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
335
50 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 50-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
336
HbA1c: 6.6% (H). FBS: 291 mg/dL (H).
Your diabetes blood test results: HbA1c is 6.6%, which is at the diabetes target. Your diabetes is reasonably well controlled. Fasting blood sugar was 291, which is high (normal is 70-100). Continue current diabetes treatment plan.
Endocrinology
Lab Result
high
337
84 y/o F with PMH of PAD, HTN, Parkinson's disease, DVT/PE on warfarin, admitted for pyelonephritis. UA showed infection. Flank pain and fever. IV antibiotics started. Managed per protocol with improvement. Strict I&O, daily weights. D/C on montelukast 10mg QHS, methotrexate 15mg weekly, acetaminophen 650mg Q6H PRN, Au...
A 84-year-old woman with a history of poor blood flow in the legs [peripheral artery disease], high blood pressure, Parkinson's disease, and blood clots [on blood thinner warfarin] was admitted for a serious kidney infection. Urine test confirmed infection. Flank pain and fever. IV antibiotics started. They were treate...
Urology
Discharge Summary
high
338
79 y/o F with PMH of ESRD on HD, gout, admitted for upper GI bleeding. Hematemesis noted. EGD showed bleeding ulcer. Managed per protocol with improvement. Strict I&O, daily weights. D/C on rosuvastatin 10mg QHS, Lantus 20U QHS, ondansetron 4mg Q8H PRN N/V, warfarin 5mg daily. F/U surgery in 10 days.
A 79-year-old woman with a history of kidney failure requiring dialysis, and gout 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. Track how much you drink and urinate. Weigh yourself every morning.. M...
Gastroenterology
Discharge Summary
high
339
23 y/o M with PMH of CKD Stage 4, s/p CABG, admitted for STEMI. ECG showed ST elevation. Troponin markedly elevated. Managed per protocol with improvement. Daily weights, 1.5L fluid restriction, low sodium diet. D/C on amoxicillin 500mg TID x 10 days, Spiriva 18mcg daily, rosuvastatin 10mg QHS, omeprazole 20mg AC break...
A 23-year-old man with a history of advanced kidney disease, and prior heart bypass surgery 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. Weigh yourself every morning before eat...
Cardiology
Discharge Summary
high
340
Procedure: ORIF L distal radius. Pt 24 y/o F. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed.
This note describes surgery to fix a wrist fracture with plate and screws for a 24-year-old woman. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders.
Orthopedics
Procedure Note
high
341
30 y/o M with PMH of OSA on CPAP, DM1, GERD, admitted for AECOPD. O2 sat dropped. Required supplemental oxygen. Managed per protocol with improvement. Compression stockings when ambulating. D/C on glipizide 5mg BID AC, amlodipine 10mg daily, lisinopril 10mg daily, prednisone taper, tramadol 50mg Q6H PRN pain. F/U hemat...
A 30-year-old man with a history of sleep apnea [uses a breathing machine at night], type 1 diabetes, and acid reflux 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. Wear compression stockin...
Pulmonology
Discharge Summary
high
342
Rx: Tab ferrous sulfate 325mg BID. Tab ondansetron 4mg Q8H PRN N/V. Adv: weight bearing exercise, calcium/vit D supplementation Adv: low salt low sugar diet, regular exercise. F/U 1 week with CBC, CMP.
Your medicines: (1) iron supplement 325mg twice daily [for low blood count — take with vitamin C]. (2) ondansetron (Zofran) 4mg every 8 hours as needed [anti-nausea medicine]. Advice: do weight-bearing exercises (walking, light weights) and take calcium and vitamin D for bone strength Advice: eat less salt and sugar, a...
General
Prescription
medium
343
56 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 56-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
344
54 y/o M presenting to ED with RLQ pain x 12hrs, anorexia, low-grade fever. Vitals: BP 128/76, HR 96, T 100.8F. CT abdomen: 9mm dilated appendix with periappendiceal fat stranding, no perforation. Dx: Acute uncomplicated appendicitis. NPO, IV Zosyn. Surgery consulted for laparoscopic appendectomy. Admit surgery.
A 54-year-old man came to the emergency room with pain in the lower right belly for 12 hours, loss of appetite, and mild fever. Vital signs: blood pressure normal, heart rate slightly fast, mild fever. CT scan showed the appendix is swollen (9mm, normal <6mm) with inflammation around it but no rupture. Diagnosis: appen...
Emergency Medicine
Clinical Note
high
345
91 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 91-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
346
30 y/o M with PMH of CKD Stage 3, GERD, s/p CABG, admitted for DKA. Blood sugar >500. pH 7.1. Anion gap elevated. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on entresto 49/51mg BID, Augmentin 875/125 BID x 7 days, omeprazole 20mg AC breakfast, azithromycin 500mg day 1 then 25...
A 30-year-old man with a history of moderate kidney disease, acid reflux, and prior heart bypass surgery 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 ...
Endocrinology
Discharge Summary
high
347
HbA1c: 10.9% (H). FBS: 88 mg/dL (N).
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 88, which is normal (normal is 70-100). Urgent medication adjustment needed. Very high risk of diabetes complications at this level.
Endocrinology
Lab Result
high
348
LFTs: AST 288 (H), ALT 441 (H), ALP 223, T.Bili 3.4 (H), Albumin 2.7.
Your liver blood test results: Liver enzymes (AST 288, ALT 441) are severely elevated, indicating significant liver damage (normal is under 40). Bilirubin is high at 3.4 (normal under 1.2) — may cause yellowing of skin and eyes [jaundice]. Albumin is low at 2.7 (normal 3.5-5.5), suggesting the liver is struggling to ma...
Gastroenterology
Lab Result
high
349
Rx: Tab glipizide 5mg BID AC. Tab ferrous sulfate 325mg BID. Tab Augmentin 875/125 BID x 7 days. Tab pregabalin 75mg BID. Adv: SMBG BID, diabetic diet Adv: weight bearing exercise, calcium/vit D supplementation. F/U 4 weeks with TSH, Free T4.
Your medicines: (1) glipizide 5mg twice daily before meals [helps release insulin]. (2) iron supplement 325mg twice daily [for low blood count — take with vitamin C]. (3) Augmentin 875mg twice daily for 7 days [antibiotic]. (4) pregabalin 75mg twice daily [nerve pain medicine]. Advice: check your blood sugar twice dail...
Neurology
Prescription
high
350
BMP: Na 134 (L), K 3.9 (N), BUN 68, Cr 2.4 (H), Glucose 240.
Your blood chemistry results: Sodium is low at 134 (normal 136-145), meaning too much water in your body. Potassium is normal at 3.9. Creatinine is elevated at 2.4 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 240 (high).
Nephrology
Lab Result
high
351
Rx: Tab ferrous sulfate 325mg BID. Tab hydroxychloroquine 200mg BID. Tab Xarelto 20mg daily with dinner. Tab timolol 0.5% OU BID. Adv: fall precautions, home safety evaluation Adv: low potassium diet. F/U 1 week with wound check.
Your medicines: (1) iron supplement 325mg twice daily [for low blood count — take with vitamin C]. (2) hydroxychloroquine 200mg twice daily [immune-modulating medicine — eye exams needed]. (3) Xarelto 20mg once daily with dinner [blood thinner]. (4) timolol eye drops in both eyes twice daily [lowers eye pressure for gl...
Rheumatology
Prescription
high
352
67 y/o F with PMH of gout, CAD, s/p TKR, admitted for acute pancreatitis. Lipase markedly elevated. CT showed peripancreatic inflammation. Managed per protocol with improvement. Strict I&O, daily weights. D/C on ASA 81mg daily, tramadol 50mg Q6H PRN pain, metformin 500mg BID, clopidogrel 75mg daily. F/U wound care in 3...
A 67-year-old woman with a history of gout, coronary artery disease [heart artery blockages], and prior knee replacement 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 improved. Tra...
Gastroenterology
Discharge Summary
high
353
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
354
CT Head without contrast: No midline shift. No mass effect. Chronic lacunar infarcts in bilateral basal ganglia. No acute intracranial hemorrhage. Paranasal sinuses clear.
CT scan of the head results: The brain is centered normally. There are no tumors or masses pushing on the brain. There are signs of small old strokes in the deep parts of the brain. There is no bleeding in the brain. The sinuses are clear with no infection.
Neurology
Radiology Report
high
355
61 y/o F with PMH of s/p THR, ESRD on HD, BPH, asthma, s/p TKR, admitted for acute CHF exacerbation. BNP elevated. CXR showed pulmonary edema. Managed per protocol with improvement. Strict NPO after midnight before procedure. D/C on ondansetron 4mg Q8H PRN N/V, amlodipine 5mg daily, spironolactone 25mg daily. F/U wound...
A 61-year-old woman with a history of prior hip replacement, kidney failure requiring dialysis, enlarged prostate, asthma, and prior knee replacement 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 impr...
Cardiology
Discharge Summary
high
356
Procedure: PCI with DES to LAD. Pt 63 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 heart catheter procedure to place a stent in a heart artery for a 63-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.
Cardiology
Procedure Note
high
357
43 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 43-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
358
PATH: Colon: tubular adenoma with low-grade dysplasia, completely excised.
Pathology results in plain language: Colon polyp is a benign growth with mild abnormal cells, fully removed.
Oncology
Pathology Report
high
359
MRI Lumbar Spine: Multilevel degenerative disc disease. Facet joint hypertrophy at L4-L5. Central canal stenosis at L3-L4. L4-L5 disc herniation with moderate bilateral foraminal stenosis.
MRI of the lower back results: Multiple discs in the spine are showing wear and aging. The small joints in the spine at L4-L5 are enlarged from arthritis. The spinal canal is narrowed at L3-L4, which may be pressing on the nerves. At the L4-L5 level, a disc has pushed outward [herniated] and is narrowing the nerve tunn...
Orthopedics
Radiology Report
high
360
LFTs: AST 118 (H), ALT 345 (H), ALP 145, T.Bili 4.0 (H), Albumin 4.3.
Your liver blood test results: Liver enzymes (AST 118, ALT 345) are severely elevated, indicating significant liver damage (normal is under 40). Bilirubin is high at 4.0 (normal under 1.2) — may cause yellowing of skin and eyes [jaundice]. Albumin is normal at 4.3.
Gastroenterology
Lab Result
high
361
56 y/o M with PMH of anemia, GERD, CKD Stage 4, h/o CVA, HTN, admitted for sepsis secondary to UTI. Blood cultures positive. Lactate elevated. Managed per protocol with improvement. Head injury precautions x 48hrs. D/C on sertraline 50mg daily, atorvastatin 80mg QHS, azithromycin 500mg day 1 then 250mg x 4 days, montel...
A 56-year-old man with a history of low blood count [anemia], acid reflux, advanced kidney disease, history of stroke, and high blood pressure 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 ac...
Infectious Disease
Discharge Summary
high
362
Doxycycline 100mg BID x 14 days with water; stay upright 30 min; avoid sun.
Take this antibiotic twice daily for 14 days with plenty of water, stay upright after doses, and use sun protection.
Infectious Disease
Medication Instruction
medium
363
BMP: Na 127 (L), K 4.7 (N), BUN 73, Cr 0.7 (N), Glucose 159.
Your blood chemistry results: Sodium is low at 127 (normal 136-145), meaning too much water in your body. Potassium is normal at 4.7. Creatinine is normal at 0.7. Blood sugar is 159 (high).
Nephrology
Lab Result
high
364
CBC: WBC 9.0 (N), Hgb 6.6 (L), Plt 311 (N).
Your blood count results: White blood cells are 9.0 (normal). Hemoglobin is low at 6.6, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 311, which is normal.
Hematology
Lab Result
high
365
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
366
Procedure: Laparoscopic appendectomy. Pt 31 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 31-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
367
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
368
CBC: WBC 11.5 (H), Hgb 15.8 (N), Plt 358 (N).
Your blood count results: White blood cells are 11.5 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is normal at 15.8. Platelets are 358, which is normal.
Hematology
Lab Result
high
369
Rx: Tab carvedilol 12.5mg BID. Tab amlodipine 5mg daily. Tab metformin 1000mg BID. Tab empagliflozin 10mg daily. Adv: fall precautions, home safety evaluation. F/U 1 week with CBC, CMP.
Your medicines: (1) carvedilol 12.5mg twice daily [heart medicine]. (2) amlodipine 5mg once daily [blood pressure medicine]. (3) metformin 1000mg twice daily with meals [blood sugar medicine]. (4) empagliflozin 10mg once daily [blood sugar medicine that also protects heart and kidneys]. Advice: take steps to prevent fa...
Cardiology
Prescription
high
370
80 y/o M with PMH of CKD Stage 3, DM2, admitted for TIA. Symptoms resolved. MRI negative for infarct. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on carvedilol 12.5mg BID, potassium chloride 20mEq daily, Xarelto 20mg daily with dinner, atorvastatin 80mg QHS. F/U wound care in ...
A 80-year-old man with a history of moderate kidney disease, and type 2 diabetes was admitted for a mini-stroke [temporary loss of brain function]. Symptoms resolved. MRI negative for infarct. They were treated according to standard guidelines and improved. Write down your blood sugar readings in a log book and bring i...
Neurology
Discharge Summary
high
371
CT Head without contrast: Chronic lacunar infarcts in bilateral basal ganglia. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. No mass effect. Paranasal sinuses clear. No acute intracranial hemorrhage.
CT scan of the head results: There are signs of small old strokes in the deep parts of the brain. There are aging-related changes in the brain's white matter from reduced blood flow to small vessels over time. There are no tumors or masses pushing on the brain. The sinuses are clear with no infection. There is no bleed...
Neurology
Radiology Report
high
372
51 y/o M with PMH of SLE, PAD, HFpEF, BPH, DM2, 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 methotrexate 15mg weekly, metoprolol 25mg BID, ferrous sulfate 325mg BID. F/U PCP in 2 weeks.
A 51-year-old man with a history of lupus, poor blood flow in the legs [peripheral artery disease], heart failure with stiff heart muscle, enlarged prostate, and type 2 diabetes was admitted for a stroke [blocked blood vessel in the brain]. CT scan showed acute ischemic infarct. clot-dissolving medicine was given. They...
Neurology
Discharge Summary
high
373
Enoxaparin 40mg SC daily until walking regularly.
Injection helps prevent clots until you are walking normally.
General
Medication Instruction
medium
374
CT Head without contrast: Chronic lacunar infarcts in bilateral basal ganglia. 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 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
375
MRI Lumbar Spine: Central canal stenosis at L3-L4. Facet joint hypertrophy at L4-L5. Conus medullaris at L1, normal. L5-S1 disc desiccation with mild bulge.
MRI of the lower back results: The spinal canal is narrowed at L3-L4, which may be pressing on the nerves. The small joints in the spine at L4-L5 are enlarged from arthritis. The spinal cord ends at a normal level. At the L5-S1 level, the disc is dried out [worn] with a slight bulge, but not causing significant pressur...
Orthopedics
Radiology Report
high
376
65 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 65-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
377
Delivery Note: G?P? at 39+1 weeks. Primary low-transverse C-section. Live female infant. APGAR 8/9. EBL within expected limits. Mother stable.
Birth summary: pregnancy reached about 39+1 weeks gestation. The baby was delivered by C-section through a low horizontal cut on the uterus. The newborn is a healthy female. APGAR scores were 8/9. Bleeding was normal. Mother did well after delivery.
Obstetrics
Delivery Note
high
378
CT Head without contrast: No midline shift. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. Mild generalized cerebral atrophy appropriate for age. Acute ischemic infarct in R MCA territory.
CT scan of the head results: The brain is centered normally. There are aging-related changes in the brain's white matter from reduced blood flow to small vessels over time. There is mild brain shrinkage, which is normal for your age. There is a new stroke affecting the right side of the brain, in the area supplied by t...
Neurology
Radiology Report
high
379
Delivery Note: G?P? at 40+0 weeks. SVD. Live male 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 male. APGAR scores were 9/9. Bleeding was normal. Mother did well after delivery.
Obstetrics
Delivery Note
high
380
HbA1c: 6.4% (H). FBS: 94 mg/dL (N).
Your diabetes blood test results: HbA1c is 6.4%, 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 94, which is normal (normal is 70-100). Lifestyle changes (diet, exercise, weight loss) can prevent progression to diabetes.
Endocrinology
Lab Result
medium
381
Procedure: Laparoscopic cholecystectomy. Pt 91 y/o F. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed.
This note describes minimally invasive gallbladder removal for a 91-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
382
33 y/o M with PMH of OSA on CPAP, ESRD on HD, HFrEF (EF 30%), OA, admitted for syncope. Cardiac workup and neurologic evaluation performed. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on amoxicillin 500mg TID x 10 days, metoprolol 25mg BID, montelukast 10mg QHS. F/U GI...
A 33-year-old man with a history of sleep apnea [uses a breathing machine at night], kidney failure requiring dialysis, heart failure with weak pumping (30%), and arthritis [osteoarthritis] was admitted for fainting [loss of consciousness]. Cardiac workup and neurologic evaluation performed. They were treated according...
Cardiology
Discharge Summary
high
383
Methotrexate 15mg weekly on fixed weekday only; folic acid except MTX day; avoid alcohol.
Take methotrexate only once per week on the same day — never daily. Take folic acid as directed. Avoid alcohol.
Rheumatology
Medication Instruction
low
384
Rx: Tab pregabalin 75mg BID. Tab metformin 1000mg BID. Adv: wound care with daily dressing changes. F/U 1 week with wound check.
Your medicines: (1) pregabalin 75mg twice daily [nerve pain medicine]. (2) metformin 1000mg twice daily with meals [blood sugar medicine]. Advice: change the wound dressing once daily — clean with saline, apply ointment, cover with fresh bandage. Come back in 1 week to have the wound checked.
Neurology
Prescription
medium
385
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
low
386
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
387
26 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 26-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
388
65 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 65-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
389
Thyroid panel: TSH 10.88 (H), Free T4 2.9.
Your thyroid test results: TSH is elevated at 10.88 (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
390
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
391
54 y/o F with PMH of s/p CABG, hypothyroidism, CAD, admitted for cellulitis R lower extremity. Leg was red, swollen, and warm. IV antibiotics started. Managed per protocol with improvement. BRAT diet x 48hrs, advance as tolerated. D/C on azithromycin 500mg day 1 then 250mg x 4 days, potassium chloride 20mEq daily, tram...
A 54-year-old woman with a history of prior heart bypass surgery, underactive thyroid, and coronary artery disease [heart artery blockages] was admitted for a skin infection in the right leg. Leg was red, swollen, and warm. IV antibiotics started. They were treated according to standard guidelines and improved. Eat bla...
Infectious Disease
Discharge Summary
high
392
62 y/o F with PMH of HFpEF, A-fib, 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 latanoprost 0.005% OU QHS, lisinopril 10mg daily, empagliflozin 10mg daily, montelukast 10mg QHS, albuterol ...
A 62-year-old woman with a history of heart failure with stiff heart muscle, and irregular heartbeat [atrial fibrillation] 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 impr...
Neurology
Discharge Summary
high
393
Procedure: PCI with DES to LAD. Pt 87 y/o M. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed.
This note describes heart catheter procedure to place a stent in a heart artery for a 87-year-old man. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders.
Cardiology
Procedure Note
high
394
CXR PA: No cardiomegaly. Patchy bilateral infiltrates. Increased interstitial markings suggesting pulmonary edema. Left lower lobe consolidation. Compression fracture T12.
Chest X-ray results: The heart is a normal size. There are scattered cloudy patches in both lungs suggesting infection or inflammation. There are signs of extra fluid in the lung tissue, suggesting the heart may not be pumping efficiently [pulmonary edema]. There is an area in the lower left lung that appears infected....
Pulmonology
Radiology Report
high
395
78 y/o M with PMH of obesity (BMI 38), CHF, Parkinson's disease, gout, h/o CVA, admitted for cellulitis L lower extremity. Area was red, warm, and swollen. Marked with pen to track spread. Managed per protocol with improvement. BRAT diet x 48hrs, advance as tolerated. D/C on calcium + vitamin D 600/400 daily, ASA 81mg ...
A 78-year-old man with a history of obesity, heart failure, Parkinson's disease, gout, and history of stroke was admitted for a skin infection in the left leg. Area was red, warm, and swollen. Marked with pen to track spread. They were treated according to standard guidelines and improved. Eat bland food for 48 hours (...
Infectious Disease
Discharge Summary
high
396
81 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 81-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
397
Rx: Tab metformin 1000mg BID. Tab tramadol 50mg Q6H PRN pain. Tab timolol 0.5% OU BID. Tab sertraline 50mg daily. Adv: high fiber diet, adequate hydration Adv: fall precautions, home safety evaluation. F/U 2 weeks.
Your medicines: (1) metformin 1000mg twice daily with meals [blood sugar medicine]. (2) tramadol 50mg every 6 hours as needed for pain [may cause drowsiness — max 4/day]. (3) timolol eye drops in both eyes twice daily [lowers eye pressure for glaucoma]. (4) sertraline 50mg once daily [antidepressant/anxiety medicine]. ...
Endocrinology
Prescription
high
398
55 y/o M with PMH of hypothyroidism, CHF, DM2, gout, admitted for NSTEMI. Troponin elevated confirming heart muscle damage. Managed per protocol with improvement. BRAT diet x 48hrs, advance as tolerated. D/C on metoprolol succinate 50mg daily, ciprofloxacin 500mg BID x 5 days, ferrous sulfate 325mg BID. F/U PCP in 2 we...
A 55-year-old man with a history of underactive thyroid, heart failure, type 2 diabetes, and gout 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. Eat bl...
Cardiology
Discharge Summary
high
399
26 y/o F with PMH of OA, s/p CABG, s/p THR, hypothyroidism, CHF, admitted for chest pain r/o ACS. Serial troponins and cardiac monitoring performed. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on Dulcolax 10mg QHS PRN, lisinopril 20mg daily, escitalopram 10mg daily, ibuprofen ...
A 26-year-old woman with a history of arthritis [osteoarthritis], prior heart bypass surgery, prior hip replacement, underactive thyroid, and heart failure was admitted for chest pain being evaluated for a possible heart attack. Serial troponins and cardiac monitoring performed. They were treated according to standard ...
Cardiology
Discharge Summary
high
400
48 y/o F with PMH of s/p CABG, anemia, admitted for sepsis secondary to cellulitis. Blood cultures drawn. IV antibiotics started emergently. Managed per protocol with improvement. Strict I&O, daily weights. D/C on amlodipine 10mg daily, warfarin 5mg daily, prednisone taper, gabapentin 300mg TID, azithromycin 500mg day ...
A 48-year-old woman with a history of prior heart bypass surgery, and low blood count [anemia] was admitted for a serious blood infection from a skin infection. Blood cultures drawn. IV antibiotics started emergently. They were treated according to standard guidelines and improved. Track how much you drink and urinate....
Infectious Disease
Discharge Summary
high