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1 | CT Head without contrast: No mass effect. Chronic lacunar infarcts in bilateral basal ganglia. 4cm right subdural hematoma with 5mm midline shift. | CT scan of the head results: 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 a significant blood collection (4cm) on the right side between the brain and skull, pushing the brain 5mm to the left — this is serious. | Neurology | Radiology Report | high |
2 | MRI Lumbar Spine: L5-S1 disc desiccation with mild bulge. C5-C6 disc herniation with cord compression. Multilevel degenerative disc disease. | MRI of the lower back results: At the L5-S1 level, the disc is dried out [worn] with a slight bulge, but not causing significant pressure. At C5-C6 in the neck, a disc has pushed out and is pressing on the spinal cord — this is significant. Multiple discs in the spine are showing wear and aging. | Orthopedics | Radiology Report | high |
3 | Procedure: PCI with DES to LAD. Pt 48 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 48-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 |
4 | BMP: Na 129 (L), K 3.9 (N), BUN 7, Cr 2.8 (H), Glucose 325. | Your blood chemistry results: Sodium is low at 129 (normal 136-145), meaning too much water in your body. Potassium is normal at 3.9. Creatinine is elevated at 2.8 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 325 (high). | Nephrology | Lab Result | high |
5 | CXR PA: Bilateral hilar lymphadenopathy. No cardiomegaly. Hyperinflated lungs consistent with COPD. Right middle lobe atelectasis. Right-sided pneumothorax. | Chest X-ray results: There are enlarged lymph nodes at the root of both lungs, which needs further evaluation. The heart is a normal size. The lungs appear over-inflated, which is typical of chronic lung disease [COPD/emphysema]. Part of the right lung has partially collapsed [atelectasis], possibly from mucus plugging... | Pulmonology | Radiology Report | high |
6 | US Abdomen: Moderate right hydronephrosis. Ascites moderate amount. Right kidney 10.5cm, no hydronephrosis. Left kidney 8cm, cortical thinning consistent with CKD. CBD 12mm, dilated. | Abdominal ultrasound results: The right kidney is swollen because urine is backing up [hydronephrosis], possibly from a blockage. There is a moderate amount of fluid in the belly [ascites]. Right kidney is normal size with no blockage. Left kidney is small with thin outer layer, consistent with chronic kidney disease. ... | Gastroenterology | Radiology Report | high |
7 | MRI Lumbar Spine: L5-S1 disc desiccation with mild bulge. Facet joint hypertrophy at L4-L5. | 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. | Orthopedics | Radiology Report | high |
8 | Rx: Tab ibuprofen 400mg Q6H PRN with food. Tab clopidogrel 75mg daily. Adv: high fiber diet, adequate hydration. F/U INR in 3 days. | Your medicines: (1) ibuprofen 400mg every 6 hours as needed with food [anti-inflammatory pain reliever]. (2) Plavix (clopidogrel) 75mg once daily [blood thinner]. Advice: eat plenty of fiber (fruits, vegetables, whole grains) and drink enough water. Come back in 3 days for a blood thinner level check [INR]. | Cardiology | Prescription | medium |
9 | 48 y/o M with PMH of anemia, A-fib, OA, admitted for alcohol withdrawal. CIWA protocol initiated. Lorazepam given as needed. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on montelukast 10mg QHS, metformin 1000mg BID, furosemide 40mg daily, ibuprofen 400mg Q6H PRN with f... | A 48-year-old man with a history of low blood count [anemia], irregular heartbeat [atrial fibrillation], and arthritis [osteoarthritis] was admitted for withdrawal symptoms after stopping alcohol. CIWA protocol initiated. Lorazepam given as needed. They were treated according to standard guidelines and improved. Use th... | Psychiatry | Discharge Summary | high |
10 | Rx: Tab atorvastatin 80mg QHS. Tab calcium + vitamin D 600/400 daily. Adv: elevate affected limb, compression stockings. F/U 2 weeks. | Your medicines: (1) atorvastatin 80mg at bedtime [high-dose cholesterol medicine]. (2) calcium plus vitamin D once daily [bone strengthening]. Advice: keep the affected leg elevated when resting and wear compression stockings. Come back for a check-up in 2 weeks. | Pediatrics | Prescription | medium |
11 | CT Head without contrast: No acute intracranial hemorrhage. No midline shift. 4cm right subdural hematoma with 5mm midline shift. Subarachnoid hemorrhage in bilateral sylvian fissures. Mild generalized cerebral atrophy appropriate for age. | 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 is bleeding around the brain surface, particularly in the grooves on bot... | Neurology | Radiology Report | high |
12 | 43 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 43-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 |
13 | Rx: Tab escitalopram 10mg daily. Tab Xarelto 20mg daily with dinner. Tab ibuprofen 400mg Q6H PRN with food. Do not stop abruptly, taper as directed. F/U 2 weeks with INR. | Your medicines: (1) escitalopram 10mg once daily [antidepressant/anxiety medicine]. (2) Xarelto 20mg once daily with dinner [blood thinner]. (3) ibuprofen 400mg every 6 hours as needed with food [anti-inflammatory pain reliever]. Do not suddenly stop this medicine — your doctor will gradually reduce the dose if needed.... | Psychiatry | Prescription | medium |
14 | BMP: Na 147 (H), K 3.9 (N), BUN 57, Cr 4.0 (H), Glucose 207. | Your blood chemistry results: Sodium is high at 147, meaning you may be dehydrated. Potassium is normal at 3.9. Creatinine is elevated at 4.0 (normal under 1.2), indicating your kidneys are not filtering well. Blood sugar is 207 (high). | Nephrology | Lab Result | high |
15 | Thyroid panel: TSH 14.3 (H), Free T4 0.6. | Your thyroid test results: TSH is elevated at 14.3 (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 |
16 | 87 y/o M with PMH of DM1, PAD, admitted for lower GI bleeding. Bright red blood per rectum. Hemoglobin dropping. Managed per protocol with improvement. Low potassium diet. D/C on atorvastatin 80mg QHS, furosemide 40mg daily, Xarelto 20mg daily with dinner. F/U nephrology in 1 week. | A 87-year-old man with a history of type 1 diabetes, and poor blood flow in the legs [peripheral artery 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. Avoid high-potassium foods: bananas, ora... | Gastroenterology | Discharge Summary | high |
17 | Rx: Tab escitalopram 10mg daily. albuterol MDI 2 puffs Q4-6H PRN. Adv: DASH diet, daily BP monitoring. F/U 1 week with CBC, CMP. | Your medicines: (1) escitalopram 10mg once daily [antidepressant/anxiety medicine]. (2) albuterol inhaler 2 puffs every 4-6 hours as needed [rescue inhaler for breathing]. Advice: follow the DASH diet (rich in fruits, vegetables, lean protein, low in salt) and check blood pressure at home daily. Come back in 1 week for... | Pulmonology | Prescription | medium |
18 | 89 y/o M with PMH of HTN, anxiety, admitted for acute kidney injury. Creatinine rose sharply from baseline. Managed per protocol with improvement. Diabetic diet, SMBG BID. D/C on carvedilol 12.5mg BID, atorvastatin 80mg QHS, amlodipine 10mg daily, ASA 81mg daily. F/U endocrine in 1 week. | A 89-year-old man with a history of high blood pressure, and anxiety was admitted for sudden worsening of kidney function. Kidney waste products rose sharply from baseline. They were treated according to standard guidelines and improved. Follow a diabetes-friendly diet (limit sweets and refined carbs). Check blood suga... | Nephrology | Discharge Summary | high |
19 | 56 y/o M presenting to ED with acute onset pleuritic CP, SOB, R calf swelling x 3 days. Vitals: BP 132/88, HR 112, RR 24, O2 91% on RA. D-dimer elevated. CTA chest: bilateral PE with RV strain. US R LE: popliteal DVT. Dx: Bilateral PE with DVT. Heparin drip started. Consider catheter-directed thrombolysis given RV stra... | A 56-year-old man came to the emergency room with sudden chest pain that worsens with breathing, shortness of breath, and right calf swelling for 3 days. Vital signs: blood pressure normal, heart rate fast, breathing rapid, oxygen low at 91%. A blood clot screening test was positive. CT scan confirmed blood clots in bo... | Emergency Medicine | Clinical Note | high |
20 | 32 y/o F with PMH of s/p CABG, HLD, admitted for lower GI bleeding. Bright red blood per rectum. Hemoglobin dropping. Managed per protocol with improvement. Head injury precautions x 48hrs. D/C on tramadol 50mg Q6H PRN pain, losartan 50mg daily, methotrexate 15mg weekly. F/U PCP in 1 week. | A 32-year-old woman with a history of prior heart bypass surgery, and high cholesterol was admitted for bleeding from the large intestine. Bright red blood per rectum. Hemoglobin dropping. They were treated according to standard guidelines and improved. Watch for: worsening headache, vomiting, confusion, unequal pupils... | Gastroenterology | Discharge Summary | high |
21 | LFTs: AST 439 (H), ALT 287 (H), ALP 47, T.Bili 1.8 (H), Albumin 4.8. | Your liver blood test results: Liver enzymes (AST 439, ALT 287) are severely elevated, indicating significant liver damage (normal is under 40). Bilirubin is mildly elevated at 1.8. Albumin is normal at 4.8. | Gastroenterology | Lab Result | high |
22 | 31 y/o M with PMH of A-fib, seizure disorder on Keppra, DM2, RA on MTX, COPD, admitted for DKA. Blood sugar >500. pH 7.1. Anion gap elevated. Managed per protocol with improvement. Strict I&O, daily weights. D/C on amoxicillin 500mg TID x 10 days, amlodipine 10mg daily, entresto 49/51mg BID, rosuvastatin 10mg QHS. F/U ... | A 31-year-old man with a history of irregular heartbeat [atrial fibrillation], seizure disorder [on Keppra], type 2 diabetes, rheumatoid arthritis [on immune-suppressing medicine], and chronic lung disease was admitted for diabetic ketoacidosis [dangerously high blood sugar with acid buildup]. Blood sugar >500. blood b... | Endocrinology | Discharge Summary | high |
23 | Procedure: ORIF L distal radius. Pt 84 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 84-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 |
24 | 79 y/o M with PMH of RA on MTX, DM2, admitted for upper GI bleeding. Hematemesis noted. EGD showed bleeding ulcer. Managed per protocol with improvement. Diabetic diet, SMBG BID. D/C on amlodipine 10mg daily, losartan 50mg daily, warfarin 5mg daily, metformin 500mg BID. F/U hematology in 2 weeks. | A 79-year-old man with a history of rheumatoid arthritis [on immune-suppressing medicine], and type 2 diabetes 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. Follow a diabetes-friendly diet (limit sw... | Gastroenterology | Discharge Summary | high |
25 | 64 y/o F presenting to ED with severe allergic reaction after eating shellfish, diffuse urticaria, lip/tongue swelling, wheezing. Vitals: BP 82/50, HR 132, RR 28, O2 90%. Clinical diagnosis of anaphylaxis based on exam. Dx: Anaphylaxis. Epinephrine 0.3mg IM x 2 doses. IV NS 2L bolus. IV methylprednisolone 125mg. IV dip... | A 64-year-old woman came to the emergency room with severe allergic reaction after eating shellfish — hives all over body, lips and tongue swelling, wheezing. Vital signs: blood pressure dangerously low (shock), heart rate very fast, breathing rapid, oxygen low. Examination and vital signs support a severe systemic all... | Emergency Medicine | Clinical Note | high |
26 | MRI Lumbar Spine: L4-L5 disc herniation with moderate bilateral foraminal stenosis. Conus medullaris at L1, normal. L5-S1 disc desiccation with mild bulge. | MRI of the lower back results: At the L4-L5 level, a disc has pushed outward [herniated] and is narrowing the nerve tunnels on both sides. The 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 pressure. | Orthopedics | Radiology Report | high |
27 | MRI Lumbar Spine: Central canal stenosis at L3-L4. 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 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 pressure. | Orthopedics | Radiology Report | high |
28 | Rx: Tab montelukast 10mg QHS. Tab Xarelto 20mg daily with dinner. Tab ASA 81mg daily. Tab sertraline 50mg daily. Avoid grapefruit juice. F/U 1 month with repeat imaging. | Your medicines: (1) montelukast 10mg at bedtime [asthma/allergy medicine]. (2) Xarelto 20mg once daily with dinner [blood thinner]. (3) baby aspirin 81mg once daily [prevents blood clots]. (4) sertraline 50mg once daily [antidepressant/anxiety medicine]. Do not drink grapefruit juice as it interferes with this medicati... | Cardiology | Prescription | high |
29 | Rx: Tab entresto 49/51mg BID. Tab atorvastatin 80mg QHS. prednisone taper. Adv: elevate affected limb, compression stockings Adv: smoking cessation, pulmonary rehab. F/U 2 weeks with FBS, HbA1c, lipid panel, KFT. | Your medicines: (1) Entresto 49/51mg twice daily [heart failure medicine]. (2) atorvastatin 80mg at bedtime [high-dose cholesterol medicine]. (3) prednisone steroid — dose gradually decreases as directed [do not stop suddenly]. Advice: keep the affected leg elevated when resting and wear compression stockings Advice: s... | Cardiology | Prescription | medium |
30 | HbA1c: 6.5% (H). FBS: 332 mg/dL (H). | Your diabetes blood test results: HbA1c is 6.5%, which is at the diabetes target. Your diabetes is reasonably well controlled. Fasting blood sugar was 332, which is high (normal is 70-100). Continue current diabetes treatment plan. | Endocrinology | Lab Result | high |
31 | 76 y/o M with PMH of A-fib, Parkinson's disease, admitted for TIA. Symptoms resolved. MRI negative for infarct. Managed per protocol with improvement. BRAT diet x 48hrs, advance as tolerated. D/C on lisinopril 20mg daily, atorvastatin 40mg QHS, escitalopram 10mg daily. F/U neurology in 2 weeks. | A 76-year-old man with a history of irregular heartbeat [atrial fibrillation], and Parkinson's disease 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. Eat bland food for 48 hours (bananas, ri... | Neurology | Discharge Summary | high |
32 | 84 y/o M with PMH of HLD, CKD Stage 4, hypothyroidism, admitted for pneumonia. CXR confirmed infiltrate. Started on IV antibiotics. Managed per protocol with improvement. Low potassium diet. D/C on metformin 1000mg BID, amoxicillin 500mg TID x 10 days. F/U nephrology in 5 days. | A 84-year-old man with a history of high cholesterol, advanced kidney disease, and underactive thyroid was admitted for a lung infection. CXR confirmed infiltrate. Started on IV antibiotics. They were treated according to standard guidelines and improved. Avoid high-potassium foods: bananas, oranges, potatoes, tomatoes... | Pulmonology | Discharge Summary | high |
33 | 54 y/o F with PMH of CKD Stage 3, s/p CABG, admitted for cellulitis R lower extremity. Leg was red, swollen, and warm. IV antibiotics started. Managed per protocol with improvement. Compression stockings when ambulating. D/C on amlodipine 5mg daily, hydroxychloroquine 200mg BID, potassium chloride 20mEq daily, warfarin... | A 54-year-old woman with a history of moderate kidney disease, and prior heart bypass surgery 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. Wear compression stockings on your legs when walking ... | Infectious Disease | Discharge Summary | high |
34 | 46 y/o F with PMH of gout, HTN, admitted for PE. CTA positive for PE. Heparin started. Managed per protocol with improvement. BRAT diet x 48hrs, advance as tolerated. D/C on Xarelto 20mg daily with dinner, omeprazole 20mg AC breakfast, losartan 50mg daily. F/U neurology in 2 weeks. | A 46-year-old woman with a history of gout, and high blood pressure was admitted for a blood clot in the lungs [pulmonary embolism]. CT scan confirmed a blood clot in the lungs. Heparin started. They were treated according to standard guidelines and improved. Eat bland food for 48 hours (bananas, rice, applesauce, toas... | Pulmonology | Discharge Summary | high |
35 | CT Head without contrast: No acute intracranial hemorrhage. No mass effect. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. | CT scan of the head results: There is no bleeding in the brain. There are no tumors or masses pushing on the brain. There are aging-related changes in the brain's white matter from reduced blood flow to small vessels over time. | Neurology | Radiology Report | high |
36 | CBC: WBC 24.3 (H), Hgb 6.0 (L), Plt 313 (N). | Your blood count results: White blood cells are 24.3 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is low at 6.0, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 313, which is normal. | Hematology | Lab Result | high |
37 | Procedure: TURP for BPH. Pt 48 y/o F. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes scope surgery to trim enlarged prostate tissue for a 48-year-old woman. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | Urology | Procedure Note | high |
38 | 40 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 40-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 |
39 | 61 y/o M with PMH of GERD, s/p CABG, admitted for syncope. Cardiac workup and neurologic evaluation performed. Managed per protocol with improvement. Head injury precautions x 48hrs. D/C on prednisone taper, montelukast 10mg QHS. F/U nephrology in 5 days. | A 61-year-old man with a history of acid reflux, and prior heart bypass surgery was admitted for fainting [loss of consciousness]. Cardiac workup and neurologic evaluation performed. They were treated according to standard guidelines and improved. Watch for: worsening headache, vomiting, confusion, unequal pupils, unus... | Cardiology | Discharge Summary | high |
40 | 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 | high |
41 | 82 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 82-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 |
42 | Lipid panel: TC 157, LDL 43, HDL 42, TG 218. | Your cholesterol results: Total cholesterol is 157. LDL (bad cholesterol) is at goal (43). HDL (good cholesterol) is good at 42. Triglycerides are high at 218. | Cardiology | Lab Result | high |
43 | Insulin lispro: count carbs and match units per sliding scale; treat lows per rule. | Fast-acting insulin dosing follows carbohydrate counting and your prescribed sliding scale; treat low blood sugar using your education handout. | Endocrinology | Medication Instruction | medium |
44 | 55 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 55-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 |
45 | Procedure: TURP for BPH. Pt 79 y/o M. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes scope surgery to trim enlarged prostate tissue for a 79-year-old man. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | Urology | Procedure Note | high |
46 | 85 y/o M with PMH of s/p TKR, s/p THR, BPH, PAD, admitted for cholecystitis. US showed gallbladder wall thickening and stones. Surgery consulted. Managed per protocol with improvement. Incentive spirometry Q1H while awake, ambulate TID. D/C on ciprofloxacin 500mg BID x 5 days, amlodipine 5mg daily, losartan 50mg daily.... | A 85-year-old man with a history of prior knee replacement, prior hip replacement, enlarged prostate, and poor blood flow in the legs [peripheral artery disease] was admitted for gallbladder infection/inflammation. US showed gallbladder wall thickening and stones. Surgery consulted. They were treated according to stand... | General Surgery | Discharge Summary | high |
47 | LFTs: AST 81 (H), ALT 460 (H), ALP 70, T.Bili 1.9 (H), Albumin 2.7. | Your liver blood test results: Liver enzymes (AST 81, ALT 460) are severely elevated, indicating significant liver damage (normal is under 40). Bilirubin is mildly elevated at 1.9. Albumin is low at 2.7 (normal 3.5-5.5), suggesting the liver is struggling to make important proteins. | Gastroenterology | Lab Result | high |
48 | Rx: Tab atorvastatin 80mg QHS. Tab metoprolol succinate 50mg daily. Tab methotrexate 15mg weekly. Tab empagliflozin 10mg daily. Tab tramadol 50mg Q6H PRN pain. Adv: fall precautions, home safety evaluation Adv: high fiber diet, adequate hydration. F/U 1 month with repeat imaging. | Your medicines: (1) atorvastatin 80mg at bedtime [high-dose cholesterol medicine]. (2) metoprolol 50mg once daily [heart rate and blood pressure medicine]. (3) methotrexate 15mg once weekly [immune-suppressing medicine for arthritis — requires monitoring]. (4) empagliflozin 10mg once daily [blood sugar medicine that al... | Cardiology | Prescription | high |
49 | 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 |
50 | Procedure: Port-a-cath placement. Pt 78 y/o F. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes implanted vein port for chemotherapy for a 78-year-old woman. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | Oncology | Procedure Note | high |
51 | 78 y/o M presenting to ED with altered mental status, found unresponsive at home. Vitals: BP 88/52, HR 128, RR 8, T 96.2F, O2 88%, GCS 8. Glucose 32 (L). UDS positive for opioids. Narcan 2mg IV x 2 with improvement. Dx: Mixed presentation: hypoglycemia + opioid overdose. D50 IV push, Narcan drip. Monitor for re-sedatio... | A 78-year-old man came to the emergency room with found unconscious at home, not responding normally. Vital signs: blood pressure dangerously low, heart rate very fast, breathing slow, temperature low, oxygen very low, barely responsive. Blood sugar was dangerously low at 32. Drug screen positive for opioids. Narcan (o... | Emergency Medicine | Clinical Note | high |
52 | 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 |
53 | 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 |
54 | HbA1c: 9.3% (H). FBS: 149 mg/dL (H). | Your diabetes blood test results: HbA1c is 9.3%, which is high, meaning your blood sugar has been poorly controlled over the past 3 months (target is under 7%). Fasting blood sugar was 149, which is high (normal is 70-100). Your diabetes treatment needs to be changed. This level increases risk of complications. | Endocrinology | Lab Result | high |
55 | 33 y/o F with PMH of OSA on CPAP, COPD, obesity (BMI 38), PAD, admitted for acute pancreatitis. Lipase markedly elevated. CT showed peripancreatic inflammation. Managed per protocol with improvement. Strict I&O, daily weights. D/C on potassium chloride 20mEq daily, levothyroxine 75mcg daily on empty stomach, timolol 0.... | A 33-year-old woman with a history of sleep apnea [uses a breathing machine at night], chronic lung disease, obesity, and poor blood flow in the legs [peripheral artery disease] was admitted for severe inflammation of the pancreas. A pancreas enzyme was very high. CT scan showed peripancreatic inflammation. They were t... | Gastroenterology | Discharge Summary | high |
56 | 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 |
57 | MRI Lumbar Spine: Central canal stenosis at L3-L4. 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 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 pressure. | Orthopedics | Radiology Report | high |
58 | Procedure: EGD with biopsy. Pt 84 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 upper endoscopy with small tissue samples taken for a 84-year-old woman. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | Gastroenterology | Procedure Note | high |
59 | 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 |
60 | 30 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 30-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 |
61 | CT Head without contrast: No acute intracranial hemorrhage. Subarachnoid hemorrhage in bilateral sylvian fissures. Chronic lacunar infarcts in bilateral basal ganglia. Periventricular white matter hypodensities consistent with chronic small vessel ischemic disease. | CT scan of the head results: There is no bleeding in the brain. There is bleeding around the brain surface, particularly in the grooves on both sides. 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... | Neurology | Radiology Report | high |
62 | Rx: Tab ibuprofen 400mg Q6H PRN with food. Tab Xarelto 20mg daily with dinner. Tab ferrous sulfate 325mg BID. Adv: high fiber diet, adequate hydration Avoid NSAIDs. F/U 2 weeks. | Your medicines: (1) ibuprofen 400mg every 6 hours as needed with food [anti-inflammatory pain reliever]. (2) Xarelto 20mg once daily with dinner [blood thinner]. (3) iron supplement 325mg twice daily [for low blood count — take with vitamin C]. Advice: eat plenty of fiber (fruits, vegetables, whole grains) and drink en... | General | Prescription | medium |
63 | CBC: WBC 16.0 (H), Hgb 15.8 (N), Plt 459 (H). | Your blood count results: White blood cells are 16.0 (high, suggesting your body is fighting an infection or inflammation). Hemoglobin is normal at 15.8. Platelets are 459, which is high — your blood may clot too easily. | Hematology | Lab Result | high |
64 | 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 |
65 | 50 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 50-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 |
66 | 36 y/o F with PMH of DVT/PE on warfarin, PAD, anxiety, admitted for lower GI bleeding. Bright red blood per rectum. Hemoglobin dropping. Managed per protocol with improvement. Blood sugar log, bring to next appointment. D/C on acetaminophen 650mg Q6H PRN, metformin 500mg BID, montelukast 10mg QHS, timolol 0.5% OU BID. ... | A 36-year-old woman with a history of blood clots [on blood thinner warfarin], poor blood flow in the legs [peripheral artery disease], and anxiety was admitted for bleeding from the large intestine. Bright red blood per rectum. Hemoglobin dropping. They were treated according to standard guidelines and improved. Write... | Gastroenterology | Discharge Summary | high |
67 | 89 y/o F with PMH of DVT/PE on warfarin, s/p THR, CKD Stage 3, ESRD on HD, asthma, 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 Xarelto 20mg daily with dinner, spironolactone 25mg daily, m... | A 89-year-old woman with a history of blood clots [on blood thinner warfarin], prior hip replacement, moderate kidney disease, kidney failure requiring dialysis, and asthma was admitted for sudden worsening of kidney function. Kidney waste products rose sharply from baseline. They were treated according to standard gui... | Nephrology | Discharge Summary | high |
68 | 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 |
69 | CBC: WBC 3.5 (L), Hgb 8.4 (L), Plt 39 (L). | Your blood count results: White blood cells are 3.5 (low, meaning your immune system may be weakened). Hemoglobin is low at 8.4, meaning you are anemic (low blood count) — you may feel tired, weak, or short of breath. Platelets are 39, which is low — your blood may not clot properly, increasing bleeding risk. | Hematology | Lab Result | high |
70 | Delivery Note: G?P? at 37+3 weeks. SVD. 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 normal vaginal delivery. The newborn is a healthy female. APGAR scores were 8/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
71 | Rx: Tab latanoprost 0.005% OU QHS. Lantus 20U QHS. Tab hydroxychloroquine 200mg BID. Tab pantoprazole 40mg AC breakfast. Tab warfarin 5mg daily. Adv: low salt low sugar diet, regular exercise. F/U 1 month with repeat imaging. | Your medicines: (1) latanoprost eye drops in both eyes at bedtime [glaucoma medicine]. (2) Lantus insulin 20 units at bedtime [long-acting insulin]. (3) hydroxychloroquine 200mg twice daily [immune-modulating medicine — eye exams needed]. (4) pantoprazole 40mg before breakfast [acid-reducing medicine]. (5) warfarin 5mg... | Gastroenterology | Prescription | high |
72 | 35 y/o F presenting to ED with seizure witnessed by family, GTC x 3 min, postictal x 15 min. Vitals: BP 152/88, HR 98, T 98.6F, GCS 14 (postictal). CT Head: no hemorrhage. BMP: Na 128 (L). Keppra level <5 (subtherapeutic). Known seizure disorder, off meds x 1 week. Dx: Breakthrough seizure secondary to medication nonco... | A 35-year-old woman came to the emergency room with a full-body seizure witnessed by family lasting about 3 minutes, followed by 15 minutes of confusion. Vital signs: blood pressure elevated (from seizure), heart rate slightly fast, no fever, mostly alert but still slightly confused. CT scan shows no bleeding. Sodium i... | Emergency Medicine | Clinical Note | high |
73 | 38 y/o M presenting to ED with severe epigastric pain radiating to back, N/V x 6hrs. Vitals: BP 138/82, HR 108, RR 20, T 100.4F. Lipase 1800 (H). CT abdomen: peripancreatic fat stranding, no necrosis. Dx: Acute pancreatitis. NPO, aggressive IVF, IV morphine, IV pantoprazole. Admit medicine. | A 38-year-old man came to the emergency room with severe upper belly pain shooting to the back with nausea and vomiting for 6 hours. Vital signs: blood pressure normal, heart rate fast, mild fever. Pancreas enzyme very high. CT scan showed severe pancreas inflammation but no dead tissue. Diagnosis: severe inflammation ... | Emergency Medicine | Clinical Note | high |
74 | 85 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 85-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 |
75 | 67 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 67-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 |
76 | Procedure: R TKA. Pt 42 y/o M. Consent obtained. Time-out performed. Procedure completed without immediate complication. Specimen/labs as indicated. Stable to PACU/floor. Post-op orders placed. | This note describes total knee replacement on the right for a 42-year-old man. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | Orthopedics | Procedure Note | high |
77 | Delivery Note: G?P? at 38+2 weeks. SVD. Live male infant. APGAR 7/9. EBL within expected limits. Mother stable. | Birth summary: pregnancy reached about 38+2 weeks gestation. The baby was delivered by normal vaginal delivery. The newborn is a healthy male. APGAR scores were 7/9. Bleeding was normal. Mother did well after delivery. | Obstetrics | Delivery Note | high |
78 | 68 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 68-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 |
79 | 70 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 70-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 |
80 | 24 y/o M with PMH of A-fib, SLE, DVT/PE on warfarin, OA, cirrhosis, admitted for appendicitis. CT confirmed. Taken to OR for laparoscopic appendectomy. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on clopidogrel 75mg daily, amlodipine 5mg daily, Spiriva 18mcg daily, methotrexate 15mg week... | A 24-year-old man with a history of irregular heartbeat [atrial fibrillation], lupus, blood clots [on blood thinner warfarin], arthritis [osteoarthritis], and liver scarring [cirrhosis] was admitted for inflammation of the appendix. CT confirmed. Taken to OR for laparoscopic appendectomy. They were treated according to... | General Surgery | Discharge Summary | high |
81 | Rx: Tab acetaminophen 650mg Q6H PRN. Tab potassium chloride 20mEq daily. Humalog per SSI. Adv: elevate affected limb, compression stockings. F/U 1 week with CBC, CMP. | Your medicines: (1) Tylenol (acetaminophen) 650mg every 6 hours as needed [do not exceed 3000mg/day]. (2) potassium supplement 20mEq once daily [replaces potassium lost from water pills]. (3) Humalog insulin before meals as directed [fast-acting insulin]. Advice: keep the affected leg elevated when resting and wear com... | General | Prescription | medium |
82 | Rx: Tab amoxicillin 500mg TID x 10 days. Tab Xarelto 20mg daily with dinner. Tab Eliquis 5mg BID. Tab methotrexate 15mg weekly. Avoid grapefruit juice Adv: elevate affected limb, compression stockings. F/U 4 weeks with TSH, Free T4. | Your medicines: (1) amoxicillin 500mg three times daily for 10 days [antibiotic — complete full course]. (2) Xarelto 20mg once daily with dinner [blood thinner]. (3) Eliquis 5mg twice daily [blood thinner]. (4) methotrexate 15mg once weekly [immune-suppressing medicine for arthritis — requires monitoring]. Do not drink... | Hematology | Prescription | high |
83 | Rx: Tab pregabalin 75mg BID. Tab azithromycin 500mg day 1 then 250mg x 4 days. Tab Dulcolax 10mg QHS PRN. Tab escitalopram 10mg daily. 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) azithromycin: 500mg on day 1, then 250mg for the next 4 days [antibiotic]. (3) Dulcolax 10mg at bedtime as needed [for constipation]. (4) escitalopram 10mg once daily [antidepressant/anxiety medicine]. Advice: change the wound dressing once dail... | Neurology | Prescription | high |
84 | 35 y/o M with PMH of GERD, OSA on CPAP, PPM in situ, CKD Stage 4, admitted for appendicitis. CT confirmed. Taken to OR for laparoscopic appendectomy. Managed per protocol with improvement. Fall precautions, PT/OT consult. D/C on metformin 1000mg BID, methotrexate 15mg weekly. F/U INR check in 3 days. | A 35-year-old man with a history of acid reflux, sleep apnea [uses a breathing machine at night], implanted pacemaker, and advanced kidney disease was admitted for inflammation of the appendix. CT confirmed. Taken to OR for laparoscopic appendectomy. They were treated according to standard guidelines and improved. Be c... | General Surgery | Discharge Summary | high |
85 | 58 y/o M presenting to ED with altered mental status, found unresponsive at home. Vitals: BP 88/52, HR 128, RR 8, T 96.2F, O2 88%, GCS 8. Glucose 32 (L). UDS positive for opioids. Narcan 2mg IV x 2 with improvement. Dx: Mixed presentation: hypoglycemia + opioid overdose. D50 IV push, Narcan drip. Monitor for re-sedatio... | A 58-year-old man came to the emergency room with found unconscious at home, not responding normally. Vital signs: blood pressure dangerously low, heart rate very fast, breathing slow, temperature low, oxygen very low, barely responsive. Blood sugar was dangerously low at 32. Drug screen positive for opioids. Narcan (o... | Emergency Medicine | Clinical Note | high |
86 | 49 y/o M presenting to ED with acute onset pleuritic CP, SOB, R calf swelling x 3 days. Vitals: BP 132/88, HR 112, RR 24, O2 91% on RA. D-dimer elevated. CTA chest: bilateral PE with RV strain. US R LE: popliteal DVT. Dx: Bilateral PE with DVT. Heparin drip started. Consider catheter-directed thrombolysis given RV stra... | A 49-year-old man came to the emergency room with sudden chest pain that worsens with breathing, shortness of breath, and right calf swelling for 3 days. Vital signs: blood pressure normal, heart rate fast, breathing rapid, oxygen low at 91%. A blood clot screening test was positive. CT scan confirmed blood clots in bo... | Emergency Medicine | Clinical Note | high |
87 | PATH: LN bx: reactive lymphoid hyperplasia, no evidence of lymphoma. | Pathology results in plain language: Lymph node sample shows reactive swelling from infection/inflammation, not lymphoma. | Hematology | Pathology Report | high |
88 | 83 y/o F with PMH of depression, h/o TIA, 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 furosemide 40mg daily, Xarelto 20mg daily with dinner. F/U nephrology in 1 week. | A 83-year-old woman with a history of depression, and history of mini-stroke 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. Limit fluids to about 6 cups p... | Nephrology | Discharge Summary | high |
89 | Rx: Tab Xarelto 20mg daily with dinner. Tab pregabalin 75mg BID. Tab Eliquis 5mg BID. Tab methotrexate 15mg weekly. Tab spironolactone 25mg daily. Avoid grapefruit juice. F/U 2 weeks. | Your medicines: (1) Xarelto 20mg once daily with dinner [blood thinner]. (2) pregabalin 75mg twice daily [nerve pain medicine]. (3) Eliquis 5mg twice daily [blood thinner]. (4) methotrexate 15mg once weekly [immune-suppressing medicine for arthritis — requires monitoring]. (5) spironolactone 25mg once daily [heart-prot... | Hematology | Prescription | high |
90 | MRI Lumbar Spine: Facet joint hypertrophy at L4-L5. L4-L5 disc herniation with moderate bilateral foraminal stenosis. | MRI of the lower back results: The small joints in the spine at L4-L5 are enlarged from arthritis. At the L4-L5 level, a disc has pushed outward [herniated] and is narrowing the nerve tunnels on both sides. | Orthopedics | Radiology Report | high |
91 | 52 y/o F with PMH of HFpEF, DM1, seizure disorder on Keppra, admitted for acute CHF exacerbation. BNP elevated. CXR showed pulmonary edema. Managed per protocol with improvement. Head injury precautions x 48hrs. D/C on Augmentin 875/125 BID x 7 days, latanoprost 0.005% OU QHS, rosuvastatin 10mg QHS. F/U INR check in 3 ... | A 52-year-old woman with a history of heart failure with stiff heart muscle, type 1 diabetes, and seizure disorder [on Keppra] 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. Watch for: worsen... | Cardiology | Discharge Summary | high |
92 | Rx: Tab ondansetron 4mg Q8H PRN N/V. Tab amlodipine 5mg daily. Tab levothyroxine 75mcg daily on empty stomach. Tab furosemide 40mg daily. albuterol MDI 2 puffs Q4-6H PRN. Adv: low salt low sugar diet, regular exercise. F/U 2 weeks with INR. | Your medicines: (1) ondansetron (Zofran) 4mg every 8 hours as needed [anti-nausea medicine]. (2) amlodipine 5mg once daily [blood pressure medicine]. (3) levothyroxine 75mcg on empty stomach 30 min before breakfast [thyroid medicine]. (4) furosemide (Lasix) 40mg once daily [water pill to remove extra fluid]. (5) albute... | Cardiology | Prescription | low |
93 | Lipid panel: TC 128, LDL 207, HDL 48, TG 137. | Your cholesterol results: Total cholesterol is 128. LDL (bad cholesterol) is very high at 207 (goal under 100), significantly increasing heart disease risk. HDL (good cholesterol) is good at 48. Triglycerides are normal at 137. | Cardiology | Lab Result | high |
94 | 65 y/o M with PMH of CKD Stage 4, ESRD on HD, OSA on CPAP, osteoporosis, DM1, admitted for HHS. Blood sugar >800. Severe dehydration. Managed per protocol with improvement. Head injury precautions x 48hrs. D/C on ibuprofen 400mg Q6H PRN with food, calcium + vitamin D 600/400 daily, empagliflozin 10mg daily, gabapentin ... | A 65-year-old man with a history of advanced kidney disease, kidney failure requiring dialysis, sleep apnea [uses a breathing machine at night], weak bones [osteoporosis], and type 1 diabetes was admitted for hyperosmolar hyperglycemic state [extremely high blood sugar]. Blood sugar >800. Severe dehydration. They were ... | Endocrinology | Discharge Summary | high |
95 | 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 |
96 | 24 y/o F with PMH of cirrhosis, anemia, admitted for syncope. Cardiac workup and neurologic evaluation performed. Managed per protocol with improvement. Seizure precautions, do not drive x 6 months. D/C on entresto 49/51mg BID, prednisone taper, amlodipine 10mg daily, timolol 0.5% OU BID, sertraline 50mg daily. F/U sur... | A 24-year-old woman with a history of liver scarring [cirrhosis], and low blood count [anemia] was admitted for fainting [loss of consciousness]. Cardiac workup and neurologic evaluation performed. They were treated according to standard guidelines and improved. Take seizure safety measures (no baths alone, no heights)... | Cardiology | Discharge Summary | high |
97 | Procedure: Laparoscopic appendectomy. Pt 71 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 keyhole surgery to remove the appendix for a 71-year-old man. Consent was reviewed, safety checks were done, and the procedure finished without immediate problems. The care team monitored recovery and placed routine post-procedure orders. | General Surgery | Procedure Note | high |
98 | 90 y/o F with PMH of depression, DVT/PE on warfarin, CKD Stage 4, admitted for cholecystitis. US showed gallbladder wall thickening and stones. Surgery consulted. Managed per protocol with improvement. Low potassium diet. D/C on lisinopril 20mg daily, Spiriva 18mcg daily, pantoprazole 40mg AC breakfast, montelukast 10m... | A 90-year-old woman with a history of depression, blood clots [on blood thinner warfarin], and advanced kidney disease was admitted for gallbladder infection/inflammation. US showed gallbladder wall thickening and stones. Surgery consulted. They were treated according to standard guidelines and improved. Avoid high-pot... | General Surgery | Discharge Summary | high |
99 | 81 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 81-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 |
100 | 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 | low |
End of preview. Expand in Data Studio
Mediclear Dataset (5000 rows)
Synthetic paired English dataset for clinical shorthand → patient-friendly explanation.
Derived from the schema and style of thenomdevel/mediclear_dataset_1000.
Schema
| Column | Description |
|---|---|
id |
Row index (1–5000) |
source |
Clinical / abbreviated text |
target |
Plain-language explanation |
specialty |
One of 20 medical specialties |
document_type |
One of 9 note/report types |
complexity |
high, medium, or low |
Files
mediclear_dataset_5000.csv— UTF-8 CSV with headermediclear_dataset_5000.jsonl— JSON Lines (same fields)
Generation
Regenerate locally:
python3 gen_5k.py
Disclaimer
Synthetic educational data — not for clinical decision-making.
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