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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Chest pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ y/o M w/ PMHx of recurrent DVT/PE ___ years ag... | [REDACTED] y/o M with PMHx of DVT, recently off coumadin, presenting with left leg pain, chest pain, CTA c/w b/l subsegmental PE. # PE/Chest pain: Patient presented with chest pain and leg pain. CTA showing bilateral subsegmental PEs. EKG with S1Q3T3. Patient with h/o recurrent DVT/PE x2, on life-long anticoagulation. ... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> CARDIOTHORACIC <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Left lower lobe lung nodules <MAJOR SURGICAL OR INVASIVE PROCEDURE> s/p left VATS and left lower lobe wedge resection X2 <HISTOR... | [REDACTED] y/o female presents for surgical excision of 2 left lower lobe lung nodules suspicious for metastatic endometrial cancer. She was taken to the operating room on [REDACTED] and underwent an uncomplicated left VATS wedge excision X2. For full details please see the operative report. She tolerated the procedure... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> SURGERY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> Dyspnea <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ POD3 from lap-assisted R hemicolectomy for suspected CRC of mid-ascending colon di... | Patient is a [REDACTED] who was readmitted on the day of discharge [REDACTED] s/p R hemicolectomy for adenocarcinoma with shortness of breath. He was found to have a right upper lobe pneumonia and a small subsegmental right middle lobe pulmonary embolism. He was admitted for IV antibiotics ceftriaxone and azithromycin,... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> SURGERY <ALLERGIES> Vancomycin / Morphine / Remicade / Compazine <ATTENDING> ___. <CHIEF COMPLAINT> Failed ileoanal pouch <MAJOR SURGICAL OR INVASIVE PROCEDURE> Removal of ileoanal pouch <HISTORY OF PRESENT ILLNESS> ___ yoM with long ... | Mr. [REDACTED] was transferred to the General Surgery service on [REDACTED] to undergo removal of ileoanal pouch for recurent pouchitis. The patient tolerated the procedure well (the reader is referred to the operative note for details) and after a brief, uneventful stay in the PACU was transferred to the floor in stab... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> Bactrim / Epinephrine <ATTENDING> ___. <CHIEF COMPLAINT> UTI <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ with metastatic neuroendocrine carcinoma and a UTI see for fatigue and hypo... | This is a [REDACTED] year old female with past medical history of breast cancer status post bilateral mastectomy, on chemotherapy for metastatic pancreatic versus ampullary neuroendocrine carcinoma, admitted [REDACTED] with confusion, found to have a UTI, course notable hypoxia thought to relate to new diagnosis of hea... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> PSYCHIATRY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> "I don't know what happened. They just showed up at the door." <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PR... | 1. LEGAL Patient refused to sign a CV on admission and was admitted on a [REDACTED] on [REDACTED]. The patient agreed to sign a CV section 10 & 11 on [REDACTED]. 2. PSYCHIATRIC On admission the patient's Haldol was increased to 5mg PO BID with PRN doses as needed throughout the day. The patient was continued on Celexa ... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> Subdural hematoma and hyponatremia <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> This is a ___ ye... | Mr. [REDACTED] is a [REDACTED] year old gentleman with PMH significant for HTN, hemochromatosis, prostate cancer s/p resection, who experienced an unwitnessed syncopal episode one week prior to presentation who was transferred from [REDACTED] for further management of bilateral SDH and hyponatremia. . # Subdural hemato... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> SURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Right abdominal and groin pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: EVAR of right CIA aneurysm, fem-fem bypass <HISTORY OF PRESE... | The patient was admitted to the vascular surgery service after surgical repair of his aneurysm. Neuro: The patient was initially kept intubated and sedated. On POD0 his sedation was weaned and was awake and following commands. His pain was managed with IV medications with good effect and then transitioned to oral pain ... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> Penicillins <ATTENDING> ___ <CHIEF COMPLAINT> Cough, dyspnea <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Mr. ___ is a ___ man with a history of opiate use disorder, previously on subox... | PATIENT SUMMARY: ==================== Mr. [REDACTED] is a [REDACTED] man with no known medical history, who presented with cough, fever, congestion x 1 week, who was initiated on antibiotic treatment for CAP. Also, he was seeking help in getting sober and receiving management of withdrawal symptoms. ===================... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> atorvastatin / influenza virus vacc,specific / ppd <ATTENDING> ___. <CHIEF COMPLAINT> nonhealing distal ___ toe distal gangrene and rest pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: left groin cutdown and CIA/E... | Ms. [REDACTED] is a [REDACTED] with left nonhealing distal [REDACTED] toe distal gangrene and rest pain who was admitted to the [REDACTED] [REDACTED] on [REDACTED]. The patient was taken to the endovascular suite and underwent planned left femoral endarterectomy and iliac stents. However, after groin cutdown and common... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> Tetracycline / Iodine / Latex <ATTENDING> ___ <CHIEF COMPLAINT> Weakness, malaise, anorexia <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Mr. ___ is a very pleasant ___ year-old man with... | This is a [REDACTED] year old man who presented with fatigue and severe weakness. He was chronically ill and immunosuppressed from chemotherapy and wide spread malignancy. He was initially treated for "pneumonia" with vancomycin, levofloxacin, and cefepime but all of these medications were discontinued the following da... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <MAJOR SURGICAL OR INVASIVE PROCEDURE> ERCP (___) attach <PERTINENT RESULTS> ADMISSION LABS: ___ 06: 16PM BLOOD WBC-13.0* RBC-4.47* Hgb-13.1* Hct-38.6* ... | [REDACTED] man with history of hypertension, [REDACTED] esophagus presenting with abdominal pain and found to have cholangitis and cholecystitis s/p ERCP with stone removal c/b oozing s/p placement of FCMS, with plans for outpatient cholecystectomy. ACUTE/ACTIVE PROBLEMS: # Cholecystitis/cholangitis: # Choledocholithia... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> erythromycin base <ATTENDING> ___. <CHIEF COMPLAINT> Neck pain, chest pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None. <HISTORY OF PRESENT ILLNESS> A ___ y/o F presents to the ED as a transfer with chest pain s/p ... | Ms. [REDACTED] is a [REDACTED] yo F who presented to the Emergency department as a transfer from outside hospital after sustaining a motor vehicle crash. She underwent CT head, chest, and torso that showed a C2 transverse foramen fracture, sternal fracture, and mediastinal hematoma. Neurosurgery was consulted and recom... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> invasive lobular carcinoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> right simple mastectomy <HISTORY OF PRESENT ILLNESS> The patient is a... | Patient was admitted on [REDACTED] and underwent a right simple mastectomy. Please refer to Dr. [REDACTED] note of same date for further details. Surgery was without complication and patient was transferred to the PACU in stable condition. Patient was then transferred to the floor. Pain was controlled on a PCA, which w... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Nausea, vomiting, diarrhea <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo M with multiple myeloma s/p ... | This is a [REDACTED] yo M with multiple myeloma s/p 10 cycles of REvlimid/Velcade/Decadron, s/p high dose Cytoxan and auto-stem cell transplant, recently discharged on [REDACTED], who p/w N/V/diarrhea. . # N/V/Diarrhea: Pt's CBC shows no longer neutropenic, and as such, less suspicion for infx process in setting of sev... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> Epistaxis <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ with hx HTN, easy bleeding, on Coumad... | AP: [REDACTED] yo M with h/o DVT on warfarin(INR 1.5 ) poorly controlled HTN p/w epistaxis #. Epistaxis: Pt had 2 balloons placed in left nostril and packing placed in right nostril by ENT. Episodes of bleeding were treating with genorous doses of afrin to the right nostril. Vit K was given. The patient is on coumadin ... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> ORTHOPAEDICS <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> ___, overall healthy with R radius fracture secondary to gun shot wound <MAJOR SURGICAL OR INVASIVE PROCEDURE> Irrigation and debr... | Patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a fracture in his right radius secondary to gunshot wound and was admitted to the orthopedic surgery service. The patient was taken to the operating room on [REDACTED] for irrigation and debride... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Fosamax / Amoxicillin / Crestor <ATTENDING> ___ <CHIEF COMPLAINT> Abdominal pain, bloating, constipation <MAJOR SURGICAL OR INVASIVE PROCEDURE> Diagnostic and therapeutic paracentesis, CT-guided biops... | The patient was admitted to Gyn Oncology from the ED for further evaluation. She had been evaluated in the ED by General Surgery and was found to have no clinical evidence of small bowel obstruction. Please see the following below for hospital course by system: . Heme/Onc: Please see attached CT and U/S reports regardi... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> General ache <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ with MS, wheelchair bound, with neurogenic b... | [REDACTED] with MS, wheelchair bound, with neurogenic bladder s/p supra pubic tube, p/w generalized body aches after sleeping on a [REDACTED] hospital bed at home. # Generalized body aches: most likely secondary to poor position while on a [REDACTED] hospital bed at home. Patient was unable to be placed in ED OBS given... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> Ibuprofen / lisinopril / Percocet <ATTENDING> ___. <CHIEF COMPLAINT> fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> ERCP EUS <HISTORY OF PRESENT ILLNESS> ___ yo M with Hep C/EtOH cirrhosis, with stage II fibrosis, p... | [REDACTED] yo man with Hep C/EtOH cirrhosis s/p Harvoni treatment with SVR, with stage II fibrosis, chronic pancreatitis, HTN, RLL squamous cell carcinoma s/p XRT, who presented with fever, abd pain, and acute cholangitis with bile obstruction, s/p ERCP with stenting, and ongoing abdominal pain. Acute cholangitis: Bile... |
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<SEX> M <SERVICE> PSYCHIATRY <ALLERGIES> penicillin <ATTENDING> ___. <CHIEF COMPLAINT> "I have a device in my head" <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Mr. ___ is a ___ y.o. ___ male with a self reported history of ... | PSYCHIATRIC Mr. [REDACTED] was admitted to [REDACTED] due to an acute decompensation of his underlying schizophrenia in the context of medication alterations just prior to hospitalization. [REDACTED] was admitted with complaints of experiencing auditory hallucinations of multiple unknown voices of both genders commenti... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> rituximab <ATTENDING> ___. <CHIEF COMPLAINT> rituxan desensitization <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old woman with marginal zone lymphoma and Waldens... | Ms. [REDACTED] is a [REDACTED] year old woman with marginal zone lymphoma and Waldenstrom's Macroglobulinemia who was admitted for Rituxan desensensitization. Her serum viscosity yesterday was 3.6 with an IgM of 3963. She did not need pheresis this morning. She received Zyrtec the morning of admission as well as benadr... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> ORTHOPAEDICS <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> s/p fall <MAJOR SURGICAL OR INVASIVE PROCEDURE> open reduction internal fixation left hip fracture <HISTORY OF PRESENT ILLNESS> Ms... | Ms [REDACTED] was evaluated in the emergency room by the orthopaedic trauma service and found to have a left hip fracture, rib fractures, and a left scapula fracture. He was admitted to Ortho and prepped for surgery on her left hip. On HD 2, she was taken to the OR. See operative report for full details. She tolerated ... |
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<SEX> F <SERVICE> SURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> right breast DCIS <MAJOR SURGICAL OR INVASIVE PROCEDURE> Right total mastectomy and sentinel lymph node biopsy: ___ <HISTORY OF PRESENT... | Ms. [REDACTED] presented as a same day admission for surgery on [REDACTED]. She was taken to the operating room where she underwent right total mastectomy and sentinel lymph node biopsy. For full details of the procedure, please see the separately dictated operative report. She tolerated the procedure well, and was ret... |
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<SEX> M <SERVICE> SURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> jaw pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> ORIF and CRMMF of mandibular symphisis and right subcondylar fractures <HISTORY OF PRES... | Mr. [REDACTED] was found to have mandibular symphysis and right subcondylar fractures, open to the mouth. He was evaluated by [REDACTED], who recommended Ancef Q8H and peridex mouth rinse BID. He was admitted to the Acute Care Surgery service. [REDACTED] then took him to the operating room on [REDACTED] for ORIF and CR... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> ORTHOPAEDICS <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Right hip OA <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: R THR <HISTORY OF PRESENT ILLNESS> ___ year old male with right hip osteoa... | The patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperat... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> UROLOGY <ALLERGIES> Coumadin / adhesive tape <ATTENDING> ___. <CHIEF COMPLAINT> Abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ s/p Cystoprostatectomy with IC and right NU in ___ ___ pT2a UC... | Patient was admitted for concern for partial small bowel obstrcuction. He was kept NPO and an NGT was placed. The NGT became dislodged on his first night in the hospital but his symptoms of nausea and abdominal pain had already resolved and he was pasing flatus so it was left out. ON hospital day one he was pasing flat... |
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<SEX> F <SERVICE> SURGERY <ALLERGIES> Iodine; Iodine Containing / Latex / Shellfish Derived <ATTENDING> ___. <CHIEF COMPLAINT> morbid obesity <MAJOR SURGICAL OR INVASIVE PROCEDURE> laparoscopic gastric band <HISTORY OF PRESENT ILLNESS> ___ has class II... | Ms. [REDACTED] was admitted to the hospital and underwent a laparoscopic gastric band. She tolerated the procedure well without complication. After a brief stay in the PACU, she was transfered to the floor. She arrived to the floor on a stage 1 bariatric diet and roxicet for pain. Over the next [REDACTED] hours, she wa... |
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<SEX> M <SERVICE> PLASTIC <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Right lower extremity wound defect <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ 1. Repair, right tibia nonunion with IM nailing and iliac... | The patient was admitted to the plastic surgery service on [REDACTED] and underwent: 1. Repair, right tibia nonunion with IM nailing and iliac crest bone grafting (ORTHOPEDICS) 2. Free flap from left thigh to right pretibial wound (PLASTIC AND RECONSTRUCTIVE SURGERY. The patient tolerated the procedures well. . Neuro: ... |
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<SEX> F <SERVICE> ORTHOPAEDICS <ALLERGIES> Penicillins <ATTENDING> ___ <CHIEF COMPLAINT> R ankle fracture <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1. ORIF right trimalleolar ankle fracture without fixation of posterior malleolus. 2. Repair distal tib/fib... | The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a R trimalleolar fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on [REDACTED] for 1. ORIF right trimalleolar ankle fracture without ... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Percocet <ATTENDING> ___ <CHIEF COMPLAINT> elevated BPs, photophobia, headache <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P1 with h/o Chiari malformation s/p SVD c/... | [REDACTED] BPs at home 180/70, headache/dizzy pt went to [REDACTED], photophobia, CT scan normal given IV 10 mg hydralazine [REDACTED] re-admission*** sent to [REDACTED] [REDACTED] to pp floor BPs 128/69, asympatomatic 130/76 postpartum floor 0600 Nifedipine 30 XL given 1800 Added Nifed 30 XL for 150/90s [REDACTED] inc... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> PSYCHIATRY <ALLERGIES> Penicillins / Sulfa (Sulfonamide Antibiotics) / Benadryl / Vistaril / Cephalosporins / lactose <ATTENDING> ___. <CHIEF COMPLAINT> "Feeling horribly physically and mentally." <MAJOR SURGICAL OR INVASIVE PROCEDURE... | GLOBAL ASSESSMENT: Mr. [REDACTED] is a [REDACTED] transgender man (female to male) with a past psychiatric history of complex PTSD, unspecified mood disorder, and borderline personality disorder, who was transferred to DEAC4 from medicine (treated for atypical pneumonia) on [REDACTED] for suicidal ideation and command ... |
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<SEX> F <SERVICE> CARDIOTHORACIC <ALLERGIES> Tetanus / albuterol <ATTENDING> ___ <CHIEF COMPLAINT> failure to thrive <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old woman s/p CABGx3 on ___ who had an u... | The patient received IV fluids and felt much better. Lopressor was discontinued and Coreg started in the setting of diminished EF (35%). She remained stable overnight and was discharged home in less than 24 hours. |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> Ampicillin / Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> hematochezia <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ with hx of CKD stage III, DM2, htn, obesity, rectal prolapse (p... | Ms. [REDACTED] was admitted and started empirically on ciprofloxacin and metronidazole, as well as given IV fluids. Dulaglutide was held as well, as GI side effects are common (usually diarrhea), though I could not find any reports of enteritis. She rapidly improved, and was able to tolerate a regular diet (with no mor... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> ACE Inhibitors <ATTENDING> ___. <CHIEF COMPLAINT> cough/fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo F with CAD s/p PCI in ___, COPD on nocturnal O2, HTN, depression with r... | [REDACTED] yo F with CAD with prior MI s/p PCI, COPD, HTN, recently diagnosed with gastric CA s/p EUS [REDACTED] showing 1.5 nodular mass at GE junction who presented to the ED with chills and cough initially concerning for pneumonia though more likely consistent with [REDACTED] aspiration pneumonitis # Aspiration Pneu... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> NEUROLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> headache <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo M no significant PMH presents with 4 days of... | Mr. [REDACTED] is a [REDACTED] yo M in a previous state of good health who presented with new onset right sided head and neck ache and R eye ptosis. He first presented to ED at [REDACTED] on [REDACTED], where they performed a CT scan which showed a right temporal hypodensity which they found concerning for underlying m... |
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<SEX> M <SERVICE> SURGERY <ALLERGIES> Ativan / Morphine <ATTENDING> ___. <CHIEF COMPLAINT> Hypotension Bacteremia? <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ direct admit from ___ for sepsis. Initially p/w hypotension ... | [REDACTED] w/ ?bacteremia and hypotension. He was admitted and had BC x 2, CBC, CHM 7, coags. He was started on Vanco. He was NPO with IVF. [REDACTED] regarding culture results - apparently, only one blood culture taken from a [REDACTED], peripheral site. No sensitivities or speciation from cultures. Report suggesting ... |
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<SEX> M <SERVICE> SURGERY <ALLERGIES> Iodine-Iodine Containing <ATTENDING> ___. <CHIEF COMPLAINT> duodenal adenoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: 1. Transduodenal resection, duodenal adenoma (T3). 2. Open cholecystectomy with common bile d... | Mr. [REDACTED] presented for planned open duodenectomy for mass excision and cholecystectomy on [REDACTED]. On post operative day 1, he had bright red blood per NGT. Aspirin, prophylactic heparin, and plavix were held, he was given a unit of pRBC and transferred to the ICU. He presented to ICU initially in hemorrhagic ... |
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<SEX> F <SERVICE> SURGERY <ALLERGIES> Amoxicillin / Levofloxacin <ATTENDING> ___. <CHIEF COMPLAINT> Abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ year old female status post laparoscopic lysis of adhesions,... | This is a [REDACTED] year old female status post laparoscopic lysis of adhesions, cholecystectomy, enterotomy repair and ventral incisional hernia repair who presented with nausea and emesis x 1. At the time of presentation her abdominal exam was benign but given recent surgery there was concern for an ileus or partial... |
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Right adnexal mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingo-oophorectom... | On [REDACTED], Ms. [REDACTED] was admitted to the gynecology service after undergoing a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, omental and peritoneal biopsies, appendectomy, right ureterolysis, and cystoscopy for a complex right adnexal mass with intra-op pathology consistent with borderline ... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> SURGERY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Fever, chills, abdominal pain, emesis <MAJOR SURGICAL OR INVASIVE PROCEDURE> Resection of duodenal mass with end-to-end duod... | The patient underwent a resection of duodenal mass on [REDACTED]. Afterwards he was provided with a PCA for pain control and was initially made NPO. An NGT was left in place for gastrointestinal decompression and IVF were provided for hydration. Return of bowel function was awaited. He developed a post-operative ileus ... |
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> symptomatic fibroid uterus, stress urinary incontinence <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterec... | On [REDACTED], Ms. [REDACTED] was admitted to the gynecology service after undergoing total laparoscopic hysterectomy, bilateral salpingectomy Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid, toradol. On post-op... |
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<SEX> M <SERVICE> NEUROSURGERY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> Seziures <MAJOR SURGICAL OR INVASIVE PROCEDURE> Left temporal craniotomy for mass resection <HISTORY OF PRESENT ILLNESS>... | Patient presented electively on [REDACTED] for resection of left temporal mass via left temporal craniotomy. He tolerated the procedure well and was extubated int he operating room. He was transported to the ICU post-operatively for observation and his post-op head CT showed minimal blood in the resection cavity. Post-... |
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<SEX> M <SERVICE> NEUROSURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Elective admission for C5-7 ACDF <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ ACDF C5-7 <HISTORY OF PRESENT ILLNESS> ___ with cervic... | Mr [REDACTED] under went a C5-7 ACDF, post-operatively he was placed in a hard cervical collar, extubated and taken to the PACU for monitoring. Post operatively, patient reported stable numbness and tingling in bilateral digits [REDACTED]. He was transferred to the floor in stable condition. On [REDACTED], patient was ... |
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Ovarian cyst and menorrhagia <MAJOR SURGICAL OR INVASIVE PROCEDURE> blood transfusion <HISTORY OF PRESENT ILLNESS> ___ y.... | [REDACTED] yo perimenopausal G0 woman with a history of heavy, painful menses and pelvic ultrasound on [REDACTED] which showed a large left an 8cm cystic left ovarian mass resembling either a chocolate cyst of endometriosis or possible a large hemorrhagic functional or follicular cyst. She was admitted to labor and del... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> Morphine / Gentamicin / Bactrim / Gyne-Lotrimin 3 / chlorhexidine <ATTENDING> ___. <CHIEF COMPLAINT> Melena <MAJOR SURGICAL OR INVASIVE PROCEDURE> EGD <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ with history of ... | Ms. [REDACTED] is a [REDACTED] with history of duodenal ulcers presenting with two days of melena and lightheadedness, found to have recurrent duodenal ulcers and barretts esophagitis. ACTIVE ISSUES: #Upper GI bleed/barretts esophagus: Pt has distant history of duodenal ulcers with EGD this admission confirming recurre... |
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<SEX> M <SERVICE> NEUROSURGERY <ALLERGIES> lisinopril <ATTENDING> ___ <CHIEF COMPLAINT> Central cord syndrome, cervical stenosis <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: C3-C6 lami and fusion <HISTORY OF PRESENT ILLNESS> ___ with history of central ... | #Central Cord Syndrome On [REDACTED], Mr. [REDACTED] presented for elective C3-C6 laminectomy and fusion. His operative course was uncomplicated, please see OMR for pertinent imaging & labs as well OR details. Postoperatively, he was monitored on the floor where he remained neurologically stable. Pain was well controll... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> Ace Inhibitors <ATTENDING> ___ <CHIEF COMPLAINT> Angioedema <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ year old male with history of gout and recently diagnosed hypertension prese... | [REDACTED] year-old male with recently diagnosed hypertension presenting with angioedema due to ACE-inhibitor. . ANGIOEDEMA: The patient was recently started on lisinopril. He was seen by ENT on admission with mild right AE fold edema. Lisinopril was discontinued and this was documented as a medication allergy. The pat... |
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<SEX> F <SERVICE> SURGERY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> morbid obesity <MAJOR SURGICAL OR INVASIVE PROCEDURE> laparoscopic gastric band placement <HISTORY OF PRESENT ILLNESS> ___ h... | Mrs. [REDACTED] was admitted to the hospital and taken to the Operating Room where she underwent a laparoscopic gastric band. She tolerated the procedure well and returned to the PACU in stable condition. Her hemodynamics were stable and her pain was well controlled with Roxicet. Following transfer to the surgical floo... |
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<SEX> F <SERVICE> SURGERY <ALLERGIES> Ampicillin / Epogen / Efavirenz <ATTENDING> ___. <CHIEF COMPLAINT> Hiatal hernia <MAJOR SURGICAL OR INVASIVE PROCEDURE> Herniorrhaphy w/ ___ fundoplication <HISTORY OF PRESENT ILLNESS> This patient is a ___ year ol... | Pt was evaluated in the Emergency Room for symptoms as described in HPI on [REDACTED] and CT scan showed persistent, unchanged hiatal hernia. She was already scheduled for a [REDACTED] fundoplication with Dr. [REDACTED] on [REDACTED], so she was discharged to home with a plan to follow up as scheduled on the [REDACTED]... |
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<SEX> M <SERVICE> SURGERY <ALLERGIES> aphalesein / tramadol / codeine / Cephalexin / amlodipine <ATTENDING> ___. <CHIEF COMPLAINT> Right great toe infection. <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ year old sp recen... | The patient was admitted to the hospital from the clinic secondary to an infected right great toe on [REDACTED]. He was started on vanco, cipro and flagyl. The warmth, redness and tenderness of the toe improved over time. He never experienced any systemic signs of infection sure as elevated wbc, temp or rigor. We perfo... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> levofloxacin <ATTENDING> ___. <CHIEF COMPLAINT> leg swelling, anemia <MAJOR SURGICAL OR INVASIVE PROCEDURE> echo <HISTORY OF PRESENT ILLNESS> ___ with NIDDM, HTN, CKD 3, chronic low back pain, recent diagnosis of ... | [REDACTED] with NIDDM, HTN, CKD 3, chronic low back pain, recent diagnosis of [REDACTED] fistula(? due to constipation, planning for colorectal surgery). She is here with 10 days of worsening bilateral lower extremity swelling. also noted to have anemia, pyuria [REDACTED] edema: -medication induced, from recently incre... |
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<SEX> M <SERVICE> SURGERY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain and weakness <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ with history of HCV, ___ s/p left lateral segmentectomy in ___... | Mr. [REDACTED] was admitted to the Hepatobiliary Surgical Service on [REDACTED] with abdominal pain and weakness as described above. His initial labs demonstrated a significant anemia, with a hematocrit of 19.7. Further review of his history raised the possibility of an upper GI bleed, as it was determined he had been ... |
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<SEX> F <SERVICE> NEUROSURGERY <ALLERGIES> Metformin / Glipizide <ATTENDING> ___. <CHIEF COMPLAINT> Headaches <MAJOR SURGICAL OR INVASIVE PROCEDURE> Brain Biopsy <HISTORY OF PRESENT ILLNESS> ___ y/o female with history of HIV and worsening headaches, f... | Ms. [REDACTED] was admitted to the Neurosurgery service to undergo an elective right frontal brain biopsy after a long hospitalization previously where a work up of the enhancing white matter was non diagnostic. Operative course was uncomplicated. Post operatively she was admitted to the neurosurgical floor and on POD ... |
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<SEX> M <SERVICE> PSYCHIATRY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> "I'm hearing voices of the mafia and CIA" <MAJOR SURGICAL OR INVASIVE PROCEDURE> None. <HISTORY OF PRESENT ILLNESS> Mr. ___ is a ___... | SAFETY: The pt. was initially placed on q5 minute checks and was restricted from sharps on admission. He consistently remained in good behavioral control, and was advanced to q15 minute checks. He was unit-restricted. There were no acute safety issues, and he required no physical or chemical restraints during this hos... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> food stuck in throat <MAJOR SURGICAL OR INVASIVE PROCEDURE> EGD <HISTORY OF PRESENT ILLNESS> ___ yo male with a PMHx of refl... | This is a [REDACTED] yo healthy male with history of GERD presented with the sensation that food was stuck in lower esophagus and suffered from vomiting. # food impaction - The patient likely had a food bolus obstructing his lower esophagus and causing persistent vomiting. He did vomit a small amount of the food bolus ... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> cough <MAJOR SURGICAL OR INVASIVE PROCEDURE> catheter exchange G-tube placement <HISTORY OF PRESENT ILLNESS> Mr. ___ is a ___ man with ... | [REDACTED] man with a past medical history of MSA, COPD, chronic respiratory failure s/p tracheostomy, Afib (on Eliquis), CAD, HFpEF, bilateral RAS s/p stenting, s/p suprapubic catheter, who presents with cough, dyspnea and increased sputum production, found to have significant aspiration. # PNA # Aspiration # Chronic ... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <MAJOR SURGICAL OR INVASIVE PROCEDURE> Colonoscopy (___) attach <PERTINENT RESULTS> DISCHARGE EXAM: -== Patient examined on day of discharge. AVSS, othe... | [REDACTED] y/o female with w/ hx of massive PE ([REDACTED]) on coumadin, ischemic colitis with hematocheiza ([REDACTED]), lacunar infarct, HTN, HLD presenting with 1 day of painless hematochezia, s/p colonoscopy [REDACTED] showing diverticulosis and small internal hemorrhoids without active bleeding. # Hematochezia: # ... |
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<SEX> M <SERVICE> SURGERY <ALLERGIES> Iodinated Contrast Media - IV Dye <ATTENDING> ___. <CHIEF COMPLAINT> ESRD, failed AVF <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ Left loop forearm atrioventricular graft. <HISTORY OF PRESENT ILLNESS> Per Dr. ___ pr... | On [REDACTED], he was admitted to the transplant service for heparin bridge as he was on coumadin for h/o AVR. On [REDACTED] he underwent left loop forearm atrioventricular graft. Surgeon was Dr. [REDACTED]. He was stable postop with positive bruit/thrill as well as a left radial pulse. Dressings were removed and incis... |
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<SEX> M <SERVICE> NEUROSURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> syncope <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ transphenoidal of pituitary macroadenoma <HISTORY OF PRESENT ILLNESS> This is a... | Mr. [REDACTED] was taken to the operating room on the day of admission on [REDACTED] and underwent a transphenoidal for removal of a pituitary macroadenoma. Intraoperatively, he was given 100mg of hydrocortisone as stress prophylaxis. He tolerated the procedure well and was extubated in the operating room. He was trans... |
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<SEX> F <SERVICE> SURGERY <ALLERGIES> Bactrim / Vicodin / Lasix <ATTENDING> ___. <CHIEF COMPLAINT> right lower extremity ischemia with non healing ulcer on right foot bunion <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ 1. Ultrasound-guided puncture of th... | Ms. [REDACTED] was admitted for a RLE angio prior to a planned debridement by the podiatry team. Ms. [REDACTED] was preoped and consented and taken to the agnio-suite for RLE angiogram. ANGIOGRAPHIC FINDINGS: 1. Her distal abdominal aorta had moderate diffuse disease, but no flow-limiting stenosis or aneurysm. Her righ... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> Worsening SOB <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo male with COPD p/w worsening dyspnea, SpO2 86% on room air per EMS. Rece... | [REDACTED] y/o male with COPD exacerbation and PNA, died of hypotension and MSOF. The patient was initially admitted to the hospital on [REDACTED]. He had been recently discharged on [REDACTED] with diagnosis of COPD flare, sent home on prednisone taper and azithromycin x 5 days. He was thought to have COPD exacerbatio... |
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<SEX> M <SERVICE> SURGERY <ALLERGIES> Nickel / Codeine / Dilantin / Seroquel / Hydromorphone / phenytoin <ATTENDING> ___. <CHIEF COMPLAINT> ESRD <MAJOR SURGICAL OR INVASIVE PROCEDURE> renal transplant <HISTORY OF PRESENT ILLNESS> ___ with ESRD (seconda... | On [REDACTED], he underwent donor after cardiac death kidney transplant. Surgeon was Dr. [REDACTED]. After venous and arterial anastomoses, the kidney pinked up over [REDACTED] minutes. The ureteral anastomosis was created and a double J stent was placed. A 19 [REDACTED] drain was place in the retroperitoneum around th... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> Prochlorperazine / Celexa / Dilaudid / Ambien / Methotrexate <ATTENDING> ___. <CHIEF COMPLAINT> I need a colonoscopy <MAJOR SURGICAL OR INVASIVE PROCEDURE> Endoscopy Colonoscopy <HISTORY OF PRESENT ILLNESS> ___ wi... | 1. Iron deficiency anemia: Patient noted to be guaiac positive at last admission; plan is for mag citrate tonight and colonoscopy tomorrow pending anesthesia evaluation. She underwent colonoscopy and EGD after evaluation by anesthesia. The colonoscopy showed AVMs. Her hct was stable. She did not require transfusion. Sh... |
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<SEX> F <SERVICE> ORTHOPAEDICS <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Right ankle pain and discomfort <MAJOR SURGICAL OR INVASIVE PROCEDURE> R ankle radial tendon repair and lateral ankle spur excision... | The patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Otherwise... |
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<SEX> F <SERVICE> NEUROSURGERY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> aneurysm <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ Coil embolization of Right superior hypophyseal aneurysm <HISTORY OF PRESENT ILLNESS> Ms. ___ was having episo... | On [REDACTED], Ms. [REDACTED] was taken to the angio suite on the day of admission and underwent a oil embolization of a right superior hypophyseal aneurysm. The groin site was sealed with angioseal. She tolerated the procedure well and was transferred to the Neuro ICU post-operatively while on a heparin drip which was... |
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<SEX> M <SERVICE> NEUROSURGERY <ALLERGIES> Apple / Peach <ATTENDING> ___. <CHIEF COMPLAINT> Headaches and arm numbness <MAJOR SURGICAL OR INVASIVE PROCEDURE> Diagnositic Cerebral Angiogram unable to coil residual aneursym <HISTORY OF PRESENT ILLNESS> _... | Mr [REDACTED] had a planned coiling scheduled for later this week but came in early due to his progressive tension in his neck, pressure in back of head, pressure/pain around vertex and 2 episodes of rigth leg + arm numbness/tingling. Feels overall tired and heavy. He underwent a diagnositic angiogram with attempted co... |
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<SEX> F <SERVICE> SURGERY <ALLERGIES> Codeine / Prochlorperazine / Remicade <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ pt of Dr. ___, ___ abdominal wound w/ poor healin... | On presentation to the ER the patient was febrile, with abdominal pain and possible pSBO on CT scan. The patient was initially admitted to the ICU, but was transferred to the floor the same day. Her diet was gradually advanced, she was started on octreotide, and she was pan-cultured. Broad spectrum antibiotic coverage ... |
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<SEX> F <SERVICE> SURGERY <ALLERGIES> Codeine <ATTENDING> ___. <CHIEF COMPLAINT> nausea and coffee ground emesis <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> This is an ___ with a history of bladder cancer s/p cystectomy/uro... | Ms. [REDACTED] was evaluated by the Acute Care service in the Emergency Room and admitted to the hospital for further management of her small bowel obstruction. A nasogastric tube was placed for decompression and she was hydrated with IV fluids. Following transfer to the Surgical floor she was comfortable, without abdo... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> chest pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Mr ___ is a ___ year old male who complains of L s... | Mr. [REDACTED] is an otherwise healthy [REDACTED] year old [REDACTED] driver who presented to the ED with chest pain and was found to have bilateral segmental PEs by CTA. They are likely secondary to immobilization during long trucking routes. He was admitted to medicine where he was educated on his illness and started... |
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<SEX> F <SERVICE> SURGERY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) / IV Dye, Iodine Containing <ATTENDING> ___. <CHIEF COMPLAINT> carotid stenosis <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: Left carotid endarterectomy and bovine pericardial patch a... | Ms. [REDACTED] underwent preop [REDACTED] and was taken for a Left carotid endarterectomy on [REDACTED]. She was monitored closely and was maintained on a nitro gtt overnight for blood pressure control. On POD 1 the nitro was weaned off and her home blood pressure meds were initiated. She remained stable; her foley was... |
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<SEX> M <SERVICE> ORTHOPAEDICS <ALLERGIES> Percocet <ATTENDING> ___. <CHIEF COMPLAINT> left hip pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> ORIF left hip <HISTORY OF PRESENT ILLNESS> ___ y.o. male with Alzheimer's dementia and ___ disease who presents ... | Mr. [REDACTED] as evaluated in the emergency room by the orthopaedic trauma service and found to have a left hip fracture. He was admitted to ortho and prepped for surgery. On HD 2, he was taken to the OR. See operative report for full details. He tolerated the procedure well without complication. After a brief stay in... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> COUGH <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Mr. ___ is an ___ year old man with medical history not... | Mr. [REDACTED] is a [REDACTED] with COPD, HTN, HLD, CAD s/p MI, hx of stroke who presented to the ED with cough, nausea, and weakness, likely due to upper respiratory infection and clinically improved with ceftriaxone/azithromycin, duonebs and symptomatic treatment of his cough. UPPER RESPIRATORY INFECTION WITH LEUKOCY... |
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<SEX> M <SERVICE> NEUROSURGERY <ALLERGIES> hydrochlorothiazide <ATTENDING> ___ <CHIEF COMPLAINT> L1 fracture <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: T11-L3 posterior fusion <HISTORY OF PRESENT ILLNESS> ___ s/p fall on ___ resulting in L1 fracture. ... | [REDACTED] who presented [REDACTED] for elective T11-L3 posterior fusion. A hemovac drain was placed intraop. Please see separate operative report by Dr. [REDACTED] more information. Patient was extubated and recovered in the PACU before being transferred to the floor. He was evaluated by the chronic pain service, who ... |
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<SEX> F <SERVICE> PLASTIC <ALLERGIES> Sulfa(Sulfonamide Antibiotics) <ATTENDING> ___. <CHIEF COMPLAINT> ___ with right breast ca desiring bilateral mastectomy and reconstruction <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1) Left modified radical mastectomy... | The patient was admitted to the plastic surgery service following bilateral mastectomy and tissue expander reconstruction. She recovered uneventfully in PACU and was transfered to the regular surgical floor later that day in stable condition. Her hospital course was unremarkable. Coumadin was resumed on POD#2. She was ... |
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<SEX> F <SERVICE> SURGERY <ALLERGIES> Hydrochlorothiazide <ATTENDING> ___. <CHIEF COMPLAINT> Abd pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Laparoscopic converted to open cholecystectomy. <HISTORY OF PRESENT ILLNESS> The patient presented with a somew... | Mrs. [REDACTED] was admitted to general surgery from the pacu. She was maintained as NPO with IVF/NGT. Her NGT was removed with the return of bowel function and decreased output. Her diet was slowly advanced as tolerated and medications were converted to oral. She has an uncomplicated post-op course. She will f/u with ... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Diarrhea, abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ man with recent ORIF ... | 1 Clostridium difficile colitis: Toxin positive with CT abdomen significant for severe pan-colitis, without evidence of toxic megacolon. Initiated on both oral vancomycin and IV flagyl initially; IV flagyl was stopped after his symptoms began to improve and he was continued on the PO vancomycin to complete a 14-day cou... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> ampullary adenoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> ERCP with ampullectomy and pancreatic stent removal <HISTORY OF PRESENT ILLNE... | Pt is a [REDACTED] y.o female with h.o FAP s/p colectomy, h.o bowel obstructions requiring surgery, RA on steroids/MTx, osteoporosis who presents for observation s/p ampullectomy given presence of adenoma. . #ampullary adenoma-H.O FAP and is s/p colectomy for FAP. She was found to have an adenoma at the ampulla and the... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <MAJOR SURGICAL OR INVASIVE PROCEDURE> none attach <PERTINENT RESULTS> Admission Labs: -== ___ 03: 47AM BLOOD WBC-13.1* RBC-3.25* Hgb-8.8* Hct-29.6* MCV... | Mr. [REDACTED] is a [REDACTED] male from [REDACTED] with no records available here with a history of an ileal conduit for bladder cancer [REDACTED] years ago with recurrent UTIs who presented with right-sided abdominal pain and fever secondary to a UTI. # Abdominal pain # Multidrug resistant Enterobacter cloacae UTI # ... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> Sulfa (Sulfonamide Antibiotics) / ibuprofen <ATTENDING> ___. <CHIEF COMPLAINT> Vomiting blood <MAJOR SURGICAL OR INVASIVE PROCEDURE> Upper endoscopy <HISTORY OF PRESENT ILLNESS> ___ M with history of DM, HTN, depr... | #. Upper GIB: EGD showing severe gastritis and esophagitis likely from NSAID use and GERD. HCT dropped to low 30's and remained stable. Discharged on BID omeprazole and follow up with PCP and GI from repeat endoscopy in 6 weeks. Aspirin also held until repeat EGD and patient counseled on not taking any NSAIDs or drinki... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> Erythromycin Base / morphine / Codeine <ATTENDING> ___. <CHIEF COMPLAINT> ventricular tachycardia <MAJOR SURGICAL OR INVASIVE PROCEDURE> None this hospitalization. <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo ... | Ms. [REDACTED] is a [REDACTED] yo woman with history of hypertension, recent admission to [REDACTED] for monomorphic ventricular tachycardia controlled on outpatient metoprolol and diltiazem, presented to [REDACTED] with dizziness and palpitations this morning, found to be in [REDACTED] and converted on amiodarone, now... |
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<SEX> M <SERVICE> ORTHOPAEDICS <ALLERGIES> Motrin / Nsaids / Vicodin <ATTENDING> ___. <CHIEF COMPLAINT> Bilateral hand weakness and sensory changes <MAJOR SURGICAL OR INVASIVE PROCEDURE> Anterior cervical discectomy and fusion C4/C5 <HISTORY OF PRESENT... | He was admitted to the [REDACTED] Spine Surgery Service and taken to the Operating Room for the above procedure (please refer to the dictated operative note for further details). The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postope... |
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Stock Ragweed Pollen Mixture <ATTENDING> ___. <CHIEF COMPLAINT> rupture of membranes, concern for euglycemic DKA <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary C-section <HISTORY OF PRES... | Ms. [REDACTED] is a [REDACTED] G1 now P1 who was admitted at 37w 3d and was transferred from [REDACTED] with spontaneous rupture of membranes and euglycemic diabetic ketoacidosis. She was transferred for management of euglycemic diabetic ketoacidosis which was managed with IV insulin and IV D5 half-normal saline, as we... |
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<SEX> F <SERVICE> NEUROLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Weakness <MAJOR SURGICAL OR INVASIVE PROCEDURE> L1/2 Decompressive Lumbar Laminectomy Intubation Tracheostomy EGD <HISTORY... | Ms. [REDACTED] is a [REDACTED] year-old woman with a past medical history including obesity, DMII, hyperlipidemia, and cervical spondylosis who was admitted to the [REDACTED] [REDACTED] with with lower extremity weakness and was found to have stenosis at L1-2 for which she underwent laminectomy; she subsequently develo... |
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<SEX> F <SERVICE> PSYCHIATRY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> "I had a vood spell cast on me a few years ago when I went to the traditional doctors... they told me to mix honey with some medicat... | SAFETY: The patient was placed on Q5 minute checks on admission and was advanced to Q15 minute checks. Patient was unit-restricted. There were no acute safety or behavioral issues during this hospitalization. LEGAL: [REDACTED] PSYCHIATRIC: On admission to Deaconess 4, patient was significantly paranoid with a fixed del... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> Macrolide Antibiotics / Phenergan / Doxycycline / Erythromycin Base / Zithromax / Tetracycline <ATTENDING> ___ <CHIEF COMPLAINT> Chest and back pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ... | [REDACTED] year old female with history of polysubstance abuse, recent MRSA endocarditis s/p 4 weeks of daptomycin, who presented with chest and back pain in the setting of incarceration for IV drug possession. She left against medical advice. #. History of recent tricuspid endocarditis: She is status-post a 4-week cou... |
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<SEX> F <SERVICE> NEUROSURGERY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) / oxycodone / hydromorphone / Dilantin <ATTENDING> ___ <CHIEF COMPLAINT> Back pain and radiculopathy <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: L3 laminectomy and L3-L4 microdi... | [REDACTED] yo female with low back pain and radiculopathy presents for elective L3 laminectomy and L3/4 microdiscectomy. #s/p L3 laminectomy and L3/4 microdiscectomy The patient tolerated the procedure well and was extubated in the OR. She was transferred to PACU where she remained hemodynamically and neurologically st... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> NEUROSURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Cerebral aneurysm <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: Pipeline Embolization rt ICA aneurysm <HISTORY OF PRESENT ILLNESS> _... | On [REDACTED], Ms. [REDACTED] presented for elective pipeline embolization of right paraclinoid aneurysm. Her procedure was uncomplicated; see [REDACTED] for full detailed procedure note. Postoperatively, she was monitored in [REDACTED] where she remained neurologically stable. Her groin site was soft without hematoma ... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> NEUROSURGERY <ALLERGIES> simvastatin / atorvastatin <ATTENDING> ___ <CHIEF COMPLAINT> Lumbar stenosis <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___- L3-5 laminectomy. <HISTORY OF PRESENT ILLNESS> Mr. ___ is a ___ y/o male with Lumbar spi... | The patient was taken to the operating room on the day of admission, [REDACTED] and underwent a L3-L5 Laminectomy. He tolerated the procedure well and was extubated in the operating room. He was then transferred to the floor for further evaluation. On [REDACTED], the patient remained neurologically intact. There was se... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> Com___ <ATTENDING> ___. <CHIEF COMPLAINT> Trauma: fell off a horse. This patient is a ___ year old female who complains of CLAVICLE AND RIB FX TRANSFER. <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESE... | This patient is a [REDACTED] year old female who complains of CLAVICLE AND RIB FX TRANSFER. She was transferred from the referring facility after she fell off a horse and per report landed on her left shoulder on [REDACTED]. CT scans of her C-spine and T. spine demonstrated a bilateral first rib fractures and L scapula... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> ___ pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo female with PMH of co... | [REDACTED] year old female with history of asthma, substance abuse, and myocardial infarction presented [REDACTED] with abdominal pain associated with fever. Brief hospital course was as follows: 1. Abdominal pain, mild leukocytosis, and fever: In emergency department, patient complained of sharp right upper quadrant p... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> left hip abscess <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ washout with VAC placement left hip ___ Washout with VAC placement left hip... | Ms. [REDACTED] presented to the [REDACTED] ([REDACTED]) on [REDACTED] as a transfer from [REDACTED] with a CT scan demonstrating a gluteal abscess and fascial thickening. She was evaluated by the Acute Care Surgery ([REDACTED]) team and admitted for possible necrotizing fasciitis versus gluteal abscess, broad spectrum ... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> tetanus toxoid, adsorbed <ATTENDING> ___ <CHIEF COMPLAINT> Fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> ERCP <HISTORY OF PRESENT ILLNESS> ___ w/ diffuse large B-cell lymphoma (diagnosed ___, recurrent in ___ and n... | [REDACTED] w/ diffuse large B-cell lymphoma (diagnosed [REDACTED], recurrent in [REDACTED] and now in remission again for one year s/p autologous stem cell transplant), and recurrent cholangitis with CBD strictures (s/p multiple ERCPs and stent replacements) who p/w very mild cholangitis and is admitted for observation... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> NEUROSURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> I hit my head" <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ was ice skating when in trying to avoid... | Pt was admitted to the neurosurgical service after sustaining TBI / SAH after falling while ice skating. Her repeat imaging was stable and she remained well. She ambulated without issue and was cleared for home by [REDACTED]. She agree'd with this plan. |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> NEUROSURGERY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> Left arterio-venous malformation. <MAJOR SURGICAL OR INVASIVE PROCEDURE> Left craniotomy for arterio-venous malformation on ___. cerebral angiogram/diagnostic ___... | The patient was taken to the operating room on the day of admission, [REDACTED] and underwent a left craniotomy and resection of arterio-venous malformation. The procedure went well. Post-operatively he underwent a diagnostic angiogram which was negative for AVM. She was admitted to the ICU post-operatively for close o... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> PSYCHIATRY <ALLERGIES> Penicillins / Codeine <ATTENDING> ___ <CHIEF COMPLAINT> "Depressed" <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ y.o. male with h/o HIV dx'd in ___ and h/o depression with multipl... | On first day of hospitalization, briefly reviewed with pt some of the circumstances leading up to his current hospitalization including his worsening depression with associated loss of interest in all activities, anhedonia, (+) neuroveg sxs, weight loss of 15 pounds in ~ 2 weeks, poor sleep, low energy, terrible concen... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> Penicillins / clindamycin <ATTENDING> ___. <CHIEF COMPLAINT> Uterine fibroids <MAJOR SURGICAL OR INVASIVE PROCEDURE> Uterine Artery Embolization <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ with PMH of uterine fi... | Ms. [REDACTED] is [REDACTED] with PMH of fibroids who presents s/p uterine artery embolization for relief of symptomatic uterine fibroid. #Uterine artery embolization post-procedure: Patient was stable s/p procedure and admission from PACU. She received excess amounts of contrast that required more aggressive hydration... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> post tace monitoring <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ chemo embolization FINDINGS: 1. Superior mesenteric arteriogram demons... | Mr. [REDACTED] is an [REDACTED] yo MW with PMH prostate CA s/p radiation, T2DM, htn, hld, h/o CVA with left residual sensory loss, chronic foot drop from helicopter accident, cirrhosis of unknown origin (likely [REDACTED]) with [REDACTED] s/p roux-en-y hepaticojejunostomy [REDACTED] now s/p TACE # 1 [REDACTED] with pos... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> ORTHOPAEDICS <ALLERGIES> Dicloxacillin <ATTENDING> ___. <CHIEF COMPLAINT> R thigh pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ on coumadin for AF pw 36 hours of R thigh pain and swelling after bump... | The patient was admitted to the orthopaedic surgery service on [REDACTED] with R thigh hematoma. Pt was admitted for monitoring for question of compartment syndrome and for reversal of INR of 4.7. Pt's coumadin was held and Vit K was administered. Upon discharge pt's INR was 1.8. Pt's PCP, [REDACTED] was contacted and ... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> All allergies / adverse drug reactions previously recorded have been deleted <ATTENDING> ___. <CHIEF COMPLAINT> Back and leg pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ male w... | [REDACTED] with sickle cell disease and beta thalassemia who presents with back and bilateral leg pain. #Pain/sickle cell disease: Presented with diffuse back and bilateral leg pain without specific findings on physical exam. No laboratory evidence of a vaso-occlusive pain episode, but patient did report this was simil... |
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