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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> ORTHOPAEDICS <ALLERGIES> Lisinopril / simvastatin / atorvastatin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) <ATTENDING> ___. <CHIEF COMPLAINT> leg pain with walking <MAJOR SURGICAL OR INVASIVE PROCEDURE> L2-L5 laminectomy with re... | Patient was admitted to the [REDACTED] Spine Surgery Service and taken to the Operating Room for the above procedure.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 [REDACTED] were used for postoperative DVT prophylaxi... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> light headedness and presyncope <MAJOR SURGICAL OR INVASIVE PROCEDURE> none - patient declined placement of Biventricular ICD device <... | The patient was transferred from [REDACTED] with reported symptoms of bradycardia, lightheadedness and pre-syncope. He has a depressed LVEF of [REDACTED] with pseudonormal filling pattern Grade II diastolic dysfunction and known ischemic cardiomyopathy as he has a history of CAD, MI [REDACTED] and NSTEMI [REDACTED] wit... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> wheezing <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> The patient is a ___ yo man with h/o asthma, depress... | Mr [REDACTED] is a [REDACTED] male with history of asthma on Advair presenting with 1 day of increasing wheezing, shortness of breath. . #. Asthma exacerbation: Presentation likely secondary to asthma flare triggered by URI/allergic rxn, further bolstered by mild eosinophila of 4% and recent exposure to dust allergens.... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> Bactrim Ds <ATTENDING> ___. <CHIEF COMPLAINT> ___ yo woman who has had intermittent non-specific abd discomfort who presents with abd pain and fever up to 102.5 at home. <MAJOR SURGICAL OR INVASIVE PROCEDURE> ERCP... | [REDACTED] with complicated biliary history requiring two ERCPs (one for retained stones, the more recent for papillary stenosis), HTN, dyslipidemia who presents with fevers, RUQ pain. Started on cipro and flagyl in the ED. She had CT in the ED and the results of the study were reviewed with pt. I asked the pt to f/u w... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> ORTHOPAEDICS <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> ___ year old man with back pain,no relief after injections or physical therapy. He had an MRI which showed L5-S1 spondylolytic spon... | 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... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Altered mental status <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ - Dobhoff tube placement <HISTORY OF PRESENT ILLNESS> ___ male with un... | Patient Summary ================== Mr [REDACTED] is a [REDACTED] year old [REDACTED] man with unknown past medical history who was initially found down with blood around the mouth, blood alcohol 239 on admission, labs consistent with alcoholic cirrhosis / alcohol hepatitis, who progressively became agitated, diaphoreti... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> morphine / Reglan / Phenergan <ATTENDING> ___. <CHIEF COMPLAINT> Foreign body ingestion <MAJOR SURGICAL OR INVASIVE PROCEDURE> Upper endoscopy <HISTORY OF PRESENT ILLNESS> This is a ___ year old male with PMHx gas... | Mr. [REDACTED] is a [REDACTED] yo M with h/o gastrectomy and Roux-en-Y surgery for gastroparesis with chronic nausea as well as iron deficiency anemia related to his gastrectomy (receives IV iron through a port) who presented with foreign body ingestion. He fell off a ladder and swallowed two nails and then had hematem... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> heparin <ATTENDING> ___ <MAJOR SURGICAL OR INVASIVE PROCEDURE> N/A attach <PERTINENT RESULTS> ADMISSION LABS -== ___ 09: 32PM BLOOD WBC-11.1* RBC-2.35* Hgb-7.4* Hct-22.1* MCV-94 MCH-31.5 MCHC-33.5 RDW-19.6* RDWSD-... | Mr. [REDACTED] is a [REDACTED] w/h/o active ETOH, decompensated alcoholic cirrhosis with refractory ascites and recent admissions for hyponateremia, paroxysmal atrial fibrillation not on anticoagulation, HTN, COPD, [REDACTED] esophagus, PVD, and moderate aortic stenosis, who initially presented to [REDACTED] on [REDACT... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Fevers <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ with history of left SI septic arthritis in ___, s... | [REDACTED] yo M w/ PMHx of DM2 and known sacral osteomyelitis treated with 6 weeks of IV Ancef ([REDACTED]) with acute on chronic left lower back pain radiating to left hip and low-grade temperatures to [REDACTED]. #SACROILIAC JOINT OSTEOARTHRITIS: Patient has a history of MSSA bacteremia and sacral osteomyelitis who c... |
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<SEX> F <SERVICE> SURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> left gluteal abscess <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: INCISION AND DRAINAGE OF LEFT GLUTEAL AND PERINEAL ABSCESS ___: INCISI... | Ms. [REDACTED] is a [REDACTED] yo F c a PMH significant for trisomy 21, diabetes mellitus and hidradenitis suppurativa. She was now admitted to the hospital after she had presented to the emergency department for an evaluation of a left-sided gluteal abscess. A CT of the pelvis with contrast on admission showed a larg(... |
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<SEX> F <SERVICE> SURGERY <ALLERGIES> Demerol <ATTENDING> ___. <CHIEF COMPLAINT> Duodenal mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ 1. Exploratory laparoscopy. 2. Radical pancreatoduodenectomy with distal gastrectomy. 3. Cholecystectomy. 4. Place... | Mrs. [REDACTED] is a [REDACTED] year old female who was admitted to [REDACTED] [REDACTED] on [REDACTED]. She was taken to the operating and underwent exploratory laparoscopy, classic pancreaticoduodenectomy, cholecystectomy, and placement of gold fiducials. She tolerated the procedure well without complications and was... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> Penicillins / Sulfa (Sulfonamide Antibiotics) <ATTENDING> ___. <CHIEF COMPLAINT> suicide attempt/overdose <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Pt is a ___ y.o female with h.o de... | Pt is a [REDACTED] y.o female with h.o depression, DM2, HTN, prior SA attempt who presents s/p suicide attempt with 20 tabs of metformin . #suicide attempt/depression-Pt reports she receives her care at [REDACTED]. Reports prior SA with metformin some years ago. States took 20 tabs of metformin 1000mg yesterday in an a... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Allergies/ADRs on File <ATTENDING> ___. <CHIEF COMPLAINT> Altered mental status <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Mr. ___ is an ___ with mental retardation who is at basel... | Mr. [REDACTED] is an [REDACTED] year old male with mental retardation who presented from outside hospital with altered mental status and CT head imaging showing multiple meningomas. # ALTERED MENTAL STATUS: Difficult to assess degree of AMS given his very limited baseline. It was brought to our attention that patient w... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Chest pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo F with HTN, HLD, non-smoker, who presented ... | [REDACTED] yo F with HTN, HLD, who presented to OSH with chest pain, ruled out, transferred to [REDACTED] for further management. . # Chest pain: On arrival, patient was asymptomatic. Heparin and nitroglycerin drips were stopped. EKG unremarkable. Cardiac enzymes negative x 2. Patient had intermittent musculoskeletal l... |
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<SEX> F <SERVICE> SURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> R breast IDC <MAJOR SURGICAL OR INVASIVE PROCEDURE> bilateral mastectomy w/ sentinel node biopsy and R limited ax dissection <HISTORY O... | Ms. [REDACTED] presented to [REDACTED] on [REDACTED] for planned bilateral mastectomy w/ sentinel node biopsy and R limited ax dissection. The operation proceeded as planned without intraoperative complications. She taken to the PACU for an initial period, then transferred to the ward for observation overnight. She was... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> NEUROSURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> skull mass at vertex of head <MAJOR SURGICAL OR INVASIVE PROCEDURE> bilateral craniotomy bilateral cranioplasty <HISTORY OF PRESEN... | [REDACTED] y/o M with no significant past medical history presents for elective bilateral craniotomies for resection of skull lesion at vertex. He was taken to the OR on [REDACTED]. He was extubated in the OR however did not wake up enough to adequately protect his airway so he was reintubated and trasnfered to the ICU... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> Sulfur / Norvasc <ATTENDING> ___. <CHIEF COMPLAINT> Abd pain, crohns flare <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ F with PMHx of Renovascular HTN c/b NSTEMI now s/p renal sten... | [REDACTED] y/o F with PMHx of Renovascular HTN s/p stenting, Gout and Crohns Dz who presents with RLQ pain and CT findings consistent with crohns flare. Hospital course: Pt slowly improved with bowel rest, IVF, antibiotics (initially ciprofloxacin and flagyl, and ultimately ciprofloxacin, flagyl, and vancomycin). She w... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> adhesive tape <ATTENDING> ___ <CHIEF COMPLAINT> symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> exam under anesthesia, abdominal myomectomy, fulgaration of endometriosis and subseros... | On [REDACTED], Ms. [REDACTED] was admitted to the gynecology service after undergoing abdominal myomectomy, fulguration of endometriosis and hysteroscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and Tora... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> ORTHOPAEDICS <ALLERGIES> amoxicillin / tree nuts <ATTENDING> ___. <CHIEF COMPLAINT> R radial shaft fx <MAJOR SURGICAL OR INVASIVE PROCEDURE> R radius ORIF <HISTORY OF PRESENT ILLNESS> ___ RHD rear-ended another car. + Airbag, - LOC. A... | The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a R radius fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on [REDACTED] for ORIF, which the patient tolerated well. For full details... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> Benadryl / zolpidem / Tylenol <ATTENDING> ___ <CHIEF COMPLAINT> ___ <MAJOR SURGICAL OR INVASIVE PROCEDURE> EGD ___ (aborted due to food in stomach) EGD ___ <HISTORY OF PRESENT ILLNESS> ___ with history of ETOH cir... | Ms. [REDACTED] is a [REDACTED] year-old woman with a history of Child's A EtOH cirrhosis (c/b varices, HE, ascites), chronic pain, and autonomic dysfunction, who presented with melena. #Melena: Guaiac positive in ED; last EGD [REDACTED] with 2 cords of small varicesHgb stable on admission, melena on rectal exam. Patien... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> Shellfish Derived / Iodine <ATTENDING> ___. <CHIEF COMPLAINT> Right arm swelling and pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None. <HISTORY OF PRESENT ILLNESS> The patient is a ___ with hx of endometriosis on ... | [REDACTED] with hx of endometriosis on OCPs who presents with RUE swelling and pain x 4 days likely [REDACTED] partial biceps tendon rupture. ACUTE ISSUES ============ # Rhabdomyolysis: In the setting of increased activity with her TRX/spin class and partial biceps tendon rupture, the pt was noted to have a CK elevatio... |
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<SEX> F <SERVICE> PSYCHIATRY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> "I'm stressed out and overwhelmed." <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> The patient r... | Ms. [REDACTED] signed a condition voluntary upon hospitalization. After one day, she was reporting feeling less depressed and was denying suicidal thoughts, intent, or plan. She participated in individual, group, and milieu therapy. She attended coping skills group and dual diagnosis group. She reported wanting to cont... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> ORTHOPAEDICS <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ ___ Complaint: R shoulder pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ R open bankart repair <HISTORY OF PRESENT ILLNESS> Patient sp fall down sta... | 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> ORTHOPAEDICS <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> Back and Lower Extremity Pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> N/A <HISTORY OF PRESENT ILLNESS> ___ transferred from ___ for spine evaluation after they per... | Patient was admitted to the [REDACTED] Spine Surgery Service and managed conservatively with pain medications and physical therapy for his lumbar disc herniation found on recent imaging. [REDACTED] were used for DVT prophylaxis.Pain was controlled with oral and IV pain medication.Diet was advanced as tolerated. The pat... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> NEUROLOGY <ALLERGIES> Nafcillin / Vancomycin / Gadolinium-Containing Agents / Shellfish <ATTENDING> ___ <CHIEF COMPLAINT> unsteady gait <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> The pt is a ___ right-han... | Ms. [REDACTED] was admitted with truncal and gait ataxia. On her exam by the Neurology stroke team, she was not noted to have truncal ataxia while in bed, but was noted to veer left on gait and she also had a positive Unterberger test (she turned to left). She had an MRI/A of her her for further evaluation. There was n... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> chest pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None. <HISTORY OF PRESENT ILLNESS> ___ lady presented to OSH due to severe, acute ons... | Ms. [REDACTED] is a [REDACTED] [REDACTED] lady transferred from [REDACTED] [REDACTED] after presenting with chest pain and found to be anemic with elevated troponin but no ST elevations on EKG. # Troponemia: Pt. managed medically for NSTEMI with beta blockers, ACEi, statin, and aspirin. Pt. also improved symptomaticall... |
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<SEX> F <SERVICE> ORTHOPAEDICS <ALLERGIES> lisinopril <ATTENDING> ___ <CHIEF COMPLAINT> Right knee osteoarthritis <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: Right total knee arthroplasty <HISTORY OF PRESENT ILLNESS> ___ w/ DM2 (Metformin), HTN, depres... | 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. Postopera... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> ___ CC / Nifedipine / Norvasc / Cortisone / Covera-HS / Hydrochlorothiazide <ATTENDING> ___. <CHIEF COMPLAINT> Fall <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ with history of HTN,... | [REDACTED] with history of HTN, HLD, Aortic stenosis, and gait disorder admitted s/p fall for syncope evaluation, found to have right wrist fractures. . # Fall: Pt had fall while walking at home with cane with no LOC or clear prodrome. Fall likely multifactorial: mechanical fall since pt reports losing her footing; acu... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> NEUROSURGERY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> hand numbness <MAJOR SURGICAL OR INVASIVE PROCEDURE> posterior cervical instrumented fusion <HISTORY OF PRESENT ILLNESS> ___ followed in clinic for cervical myelo... | Pt was admitted electively to the hospital and went to the OR where under general anesthesia he underwent posterior cervical decompression and instrumented fusion C2-7 under general anesthesia. He tolerated this procedure well and was transferred to PACU. Due to length of prone position pt had facial edema requiring in... |
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<SEX> F <SERVICE> SURGERY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> painless jaundice <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: bilateral PTBD placement <HISTORY OF PRESENT ILLNESS> Ms. ___ is an ___ woman who was noted to have jaund... | Ms. [REDACTED] was admitted to the Hepatobiliary Surgery Service following her clinic appointment on [REDACTED] for further work-up and management of her recent onset of painless jaundice. Throughout her hospital stay, Ms. [REDACTED] remained stable, afebrile, and with normal vital signs. She tolerated a normal diet du... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Dyspnea <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Mr. ___ is a ___ year-old man who presents with dyspn... | The patient is a [REDACTED] man with a medical history notable obly for childhood asthma who presents with acute onset of dyspnea following recent bronchitis suggestive of reactive airways disease. ACTIVE ISSUES: # Pneumonia/asthma exacerbation: This patient presented to the ED on [REDACTED] in moderate respiratory dis... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> CARDIOTHORACIC <ALLERGIES> Latex / Codeine / Oxycodone / Percocet / Sulfa (Sulfonamide Antibiotics) / Vicodin <ATTENDING> ___. <CHIEF COMPLAINT> Dyspnea on exertion <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ Aortic Valve Replacement (... | Mrs. [REDACTED] was a same day admit, and on [REDACTED] she was brought to the operating room where he underwent an aortic valve replacement. Please see operative note for surgical details. In summary she had an Aortic valve replacement with a 21mm [REDACTED] tissue valve. Her bypass time was 72 minutes with a crosscla... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> ___ <ATTENDING> ___ <CHIEF COMPLAINT> Status post fall x 2 <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ woman with history of DM2, HTN, back pain on narcotics presented with second ... | [REDACTED] woman with history of DM 2, HTN, back pain on narcotics and frequent falls who presented with a second fall in 2 days with broken nondisplaced distal right fibula. her falls are mechanical, in the setting of narcotic use. History and examination were not consistent with a cardiac or CNS etiology. CE negative... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> NEUROLOGY <ALLERGIES> Zestril / Fosamax <ATTENDING> ___ <CHIEF COMPLAINT> visual symptoms <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ woman with PMH significant for HTN, prior positive visual symptoms ... | [REDACTED] woman with HTN, FHx migraine but no personal history of migraine who presents with 30 minutes of visual lines in left peripheral field no migrainous HA before or after. Several past episodes of positive visual phenomena (spots and lights, unclear location). Examination is normal. Given the positive symptoms,... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> ORTHOPAEDICS <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> L1 Fracture s/p fall <MAJOR SURGICAL OR INVASIVE PROCEDURE> T11-L3 FUSION and L1 LAMINECTOMY POSTERIOR with INSTRUMENTATION on ___... | Patient was admitted to the [REDACTED] Spine Surgery Service and taken to the Operating Room for the above procedure.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 [REDACTED] were used for postoperative DVT prophylaxi... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> Penicillins / Ibuprofen / Keflex / Vancomycin <ATTENDING> ___ <CHIEF COMPLAINT> fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ MEDICINE ATTENDING ADMISSION NOTE Date: ___ Time: ... | [REDACTED] h/o gastric band [REDACTED] c/b gastric perforation s/p removal and repair [REDACTED], course c/b recurrent fever, intraabdominal collections and poor wound healing, HTN, DM, OA; p/w worsening abdominal pain and fever x 2 wk, nausea and diarrhea x 3 days. # Abdominal pain: On further history the pt complaine... |
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<SEX> M <SERVICE> UROLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> bladder outlet obstruction <MAJOR SURGICAL OR INVASIVE PROCEDURE> Cystoscopy, transurethral resection of prostate, bipolar. <HISTORY OF... | Patient was admitted to urology service after undergoing transurethral resection of prostate. Please see dictated operative report for full details. Patient's pain was well controlled on oral pain medications. His diet was advanced as tolerated. He was kept on continuous bladder irrigation overnight. This was clamped i... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> CARDIOTHORACIC <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Exertional Dyspnea <MAJOR SURGICAL OR INVASIVE PROCEDURE> Aortic Valve Replacement (23mm ___ tissue) ___ <HISTORY OF PRESENT ILL... | The patient was brought to the Operating Room on [REDACTED] where the patient underwent AVR (23mm tissue) with Dr. [REDACTED]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, a... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> abdominal pain, jaundice <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ guided liver biopsy - aborted - ___ ___ guided Liver biopsy ___ <HI... | Ms. [REDACTED] is a [REDACTED] year old woman with past medical history of tobacco abuse without a longitudinal care physician, admitted [REDACTED] with anorexia and painless jaundice, found to have cross sectional imaging concerning for metastatic malignancy of primary lung origin. #STAGE IV SMALL CELL LUNG CANCER: pt... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> Epinephrine <ATTENDING> ___. <MAJOR SURGICAL OR INVASIVE PROCEDURE> CRT-D Placement attach <PERTINENT RESULTS> Admission Labs: -== ___ 02: 15PM BLOOD WBC-9.7 RBC-4.25* Hgb-13.6* Hct-42.2 MCV-99* MCH-32.0 MCHC-32.2... | This is a [REDACTED] man with a history of hypertrophic cardiomyopathy (EF 25%), status post mechanical mitral valve replacement ([REDACTED]), CAD, hypertension, A. fib on warfarin who presents for evaluation of worsened dyspnea on exertion found to be in atrial fibrillation with RVR of s/p dignoxin as well as CRT-D pl... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> ORTHOPAEDICS <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> R hip pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> s/p right total hip replacement <HISTORY OF PRESENT ILLNESS> R hip OA <PAST MEDI... | 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... |
Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> CARDIOTHORACIC <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Chest discomfort <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ Aortic valve replacement with a ___ Onyx mechanical valve <HISTORY OF... | Mr. [REDACTED] was a same day admit and on [REDACTED] was brought directly to the operating room where he underwent an aortic valve replacement. Please see operative note for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later this day he was weaned fro... |
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<SEX> M <SERVICE> SURGERY <ALLERGIES> ciprofloxacin <ATTENDING> ___. <CHIEF COMPLAINT> chronic osteomyelitis of left second toe <MAJOR SURGICAL OR INVASIVE PROCEDURE> diagnostic LLE angiogram (___) and left second toe amp (___) <HISTORY OF PRESENT ILLN... | Due to patient's stage IV CKD status, pt was admitted for prehydration for planned LLE angiogram for evaluation of a chronic second toe osteomyelitis. Diagnostic angiogram was performed on ([REDACTED]) and showed flow up to the below-knee popliteal artery with no further tibial run-off and with reconstitution of the DP... |
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<SEX> F <SERVICE> NEUROSURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> ___ Disease, pituitary macroadenoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: Endoscopic transphenoidal Hypophysectomy <HISTORY ... | On [REDACTED], Ms. [REDACTED] was admitted for elective transphenoidal resection of pituitary adenoma. Operative course was uncomplicated, please see operative note for full details. #Pituitary Macroadenoma: On POD she remained neurologically and hemodynamically stable. She did not have any signs and symptoms of CSF le... |
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<SEX> M <SERVICE> CARDIOTHORACIC <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> dyspnea <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ Left robotic-assisted diaphragmatic plication <HISTORY OF PRESENT ILLNESS> __... | Mr. [REDACTED] was aditted to the hospital and taken to the Operating Room where he underwent a left robotic-assisted diaphragmatic plication. He tolerated the procedure well and returned to the PACU in stable condition. He maintained stable hemodynamics and his pain was controlled with Tylenol and Iv Dilaudid. An epid... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> Sulfa (Sulfonamide Antibiotics) / Codeine <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Ultrasound-guided liver biopsy <HISTORY OF PRESENT ILLNESS> ___ year old female wi... | The patient was admitted to the medicine service with pancreatitis, thought to be gallstone-related. IV fluid hydration was continued, and she was kept strictly NPO, with pain and nausea control with IV medications. # Pancreatitis The patient was initially kept strictly NPO with IV fluid resuscitation as above. However... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> Vancomycin <ATTENDING> ___ <CHIEF COMPLAINT> Fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> PICC placement <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ with a PMHx of cystic liver disease (possibly ___'s, s/p R hep... | [REDACTED] with a PMHx of cystic liver disease (possibly [REDACTED]'s, s/p R hepatic lobe resction in [REDACTED], c/b bile leak, s/p multiple PTCs/ERCP), and SVT, who p/w fever and GNR bacteremia. # Fevers/GNR bacteremia: Pt was admitted in the setting of GNR bacteremia and was treated initially with ceftriaxone and me... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> Syncope <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Briefly, ___ hx HTN, previous PE/DVT in ___, gout who synopized at home. Awoke from a... | Mr. [REDACTED] is a [REDACTED] with HTN, previous PE, gout here with syncope episode and head strike. . # SYNCOPE: Unclear etiology. Had atypical prodrome for vasovagal syncope, though the visual abnormalities could be consistent. His rapid recovery is consistent with this diagnosis. No new medications currently, and h... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> aspirin <ATTENDING> ___. <CHIEF COMPLAINT> Bilateral leg pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None. <HISTORY OF PRESENT ILLNESS> ___ F with a history of DVT/PE/thrombophilia s/p IVC filter presents with pro... | REASON FOR HOSPITALIZATION =========================== [REDACTED] F with a history of DVT/PE/thrombophilia s/p IVC filter on home warfarin presents with progressive [REDACTED] unequal bilateral leg pain over the last month. #) Leg Pain: Patient presented with unequal pain associated with healing wounds on both feet and... |
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<SEX> F <SERVICE> PODIATRY <ALLERGIES> Bactrim <ATTENDING> ___. <CHIEF COMPLAINT> Right Foot Foreign Body <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: Right Foot Incision and Drainage; Removal of Foreign Body <HISTORY OF PRESENT ILLNESS> Ms. ___ is a __... | The patient was taken to the operating room on [REDACTED] for a right foot incision and drainage with removal of foreign body. The procedure ended with successful removal of foreign body but an abscess was noted. The wound was packed open and the patient was admitted post-operatively for delayed primary closure on POD1... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> hematemesis <MAJOR SURGICAL OR INVASIVE PROCEDURE> Upper Endoscopy (___) <HISTORY OF PRESENT ILLNESS> ___ male with AF and AVR on Eliq... | Mr. [REDACTED] is an [REDACTED] man with atrial fibrillation on apixaban, bioprosthetic AVR on aspirin, HTN, who presented with upper gastrointestinal bleed and was found to ulcers the GEJ junction with stigmata of recent bleeding. ================= ACTIVE ISSUES ================= #Upper gastrointestinal bleed: #Acute ... |
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<SEX> M <SERVICE> ORTHOPAEDICS <ALLERGIES> Immune Globulin,Horse <ATTENDING> ___. <CHIEF COMPLAINT> Pain in right arm/wrist/hip/ankle and left thumb <MAJOR SURGICAL OR INVASIVE PROCEDURE> Right hip trochanteric fixation nail, open reduction, internal f... | The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right intertrochanteric fracture, right distal radius fracture, left thumb proximal phalynx fracture, multiple pelvic fractures (right iliac wing fracture, right sacral ala fracture, right... |
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G2P0 at ___ gestation who prese... | Ms. [REDACTED] is a [REDACTED] yo G2P0 who was admitted on [REDACTED] at 25w5d with threatened pre-term labor and positive FFN. There was no evidence of chorioamnionitis or abruption. She received betamethasone for lung maturity. Her cervix remained unchanged, she was asymptomatic, and fetal testing was reassuring. She... |
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<SEX> M <SERVICE> SURGERY <ALLERGIES> No Allergies/ADRs on File <ATTENDING> ___. <CHIEF COMPLAINT> acute fulminant liver failure <MAJOR SURGICAL OR INVASIVE PROCEDURE> Bolt placement by Neurosurgery Bolt removal by Neurosurgery <HISTORY OF PRESENT ILLN... | Mr. [REDACTED] was transferred from [REDACTED] due to diagnosis of fulminant liver failure on [REDACTED]. On admission patient was able to breath on RA and on neuro exam he was somnolent with periods of agitation. On arrival fulminant liver pathway was initiated for possible need of liver transplantation. Hepatology, n... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Desmoid tumor <MAJOR SURGICAL OR INVASIVE PROCEDURE> Cryoablation of residual desmoid tumor ___ <HISTORY OF PRESENT ILLNESS> This is a... | SUMMARY: [REDACTED] h/o hepatitis C, desmoid tumor presents for pain and nausea control after repeat cryoablation by [REDACTED] for residual painful desmoid tumor. She was controlled overnight on IV Zofran, dilaudid PCA, and IV toradol for breakthrough. Her pain and nausea were well-controlled and she was transitioned ... |
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<SEX> M <SERVICE> SURGERY <ALLERGIES> Seasonal Allergies <ATTENDING> ___. <CHIEF COMPLAINT> right sided chest pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: placement of chest pigtail right side ___: removal of pigtail <HISTORY OF PRESENT ILLNESS> Mr... | [REDACTED] year old male who presented to his primary care provider with right sided chest pain. Patient reported that he had fallen on the ice onto his right side. He underwent a chest x-ray which showed a right sided moderate/large pneumothorax and 8th rib fracture. There was no head strike or respiratory compromise.... |
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<SEX> M <SERVICE> SURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Right lower extremity claudication <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: R common femoral artery thrombectomy, exploration of rig... | Mr. [REDACTED] underwent a R common femoral artery thrombectomy, exploration of right peroneal artery with ligation, angio, right common femoral artery to anterior tibial artery bypass with in situ saphenous vein graft on [REDACTED]. He tolerated the procedure well. His graft was dopplerable immediately post-operativel... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> Prochlorperazine <ATTENDING> ___. <CHIEF COMPLAINT> Abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Flexible Sigmoidoscopy <HISTORY OF PRESENT ILLNESS> This is a ___ yo woman with ulcerative colitis who is a... | [REDACTED] yo woman with ulcerative colitis who presents with flare, uncontrolled pain and bloody diarrhea. Pt admitted for management of flare of UC. GI team performed sigmoidoscopy with findings consistent with ulcerative colitis. Because the patient has failed medical management, the recommendation was to have a tot... |
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<SEX> F <SERVICE> ORTHOPAEDICS <ALLERGIES> Celexa <ATTENDING> ___ <CHIEF COMPLAINT> Right leg pain s/p car strike while on bicycle <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1. Open reduction internal fixation right tibia fracture with intramedullary nail.... | The patient was admitted to the Orthopaedic Trauma Service for repair of a right tibia fracture. The patient was taken to the OR and underwent an open reduction internal fixation right tibia fracture with intramedullary nail), as well as fasciotomy of the right lower leg anterior and lateral compartment following eleva... |
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<SEX> F <SERVICE> SURGERY <ALLERGIES> Penicillins / Dilaudid (PF) / Cephalosporins / peaches / mango / tangerine <ATTENDING> ___. <CHIEF COMPLAINT> Abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ s/p cholecys... | The patient was admitted to the General Surgical Service for evaluation and treatment. Neuro: The patient received tramadol with good effect and adequate pain control. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pu... |
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Perineal pain and bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> Evacuation of left vulvar hematoma, repair of Bartholin'... | On [REDACTED], Ms. [REDACTED] was admitted to the gynecology service after undergoing an evacuation of left vulvar hematoma and repair of Bartholin marsupialization. Please see the operative report for full details. Her post-operative course was uncomplicated. She had an estimated total blood loss of 600cc (400cc preop... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> lisinopril <ATTENDING> ___ <CHIEF COMPLAINT> Chest pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ hx of CAD s/p quadruple bypass, PVD, on ASA, DM, prostate CA s/p prostatectamy p... | [REDACTED] hx of CAD s/p quadruple bypass, PVD, on ASA, DM, prostate CA s/p prostatectamy admitted for chest pain and concern for acute coronary syndrome. # Chest pain: Patient admitted for about two hours of chest pain, no diaphoresis, shortness of breath or dizziness. On admission he was afebrile but hypertensive to ... |
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<SEX> M <SERVICE> SURGERY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> Ventral Hernia <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: Ventral hernia repair with mesh <HISTORY OF PRESENT ILLNESS> Patient underwent Roux-en-Y hepaticojejunostomy... | [REDACTED] y/o male well known to this service who underwent a ventral hernia repair with mesh with Dr [REDACTED]. Please see the operative note for surgical detail. The patient tolerated the surgery without incident. He was kept overnight for monitoring and potential pain management. The patient is still using a fenta... |
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<SEX> M <SERVICE> CARDIOTHORACIC <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Cardiac Arrest <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: Coronary artery bypass grafting x2: Left internal mammary artery graf... | Mr. [REDACTED] was brought to the operating room on [REDACTED] where he underwent an Coronary artery bypass grafting x2: Left internal mammary artery graft to left anterior descending, and reverse saphenous vein graft to diagonal branch. The cardiopulmonary bypass time was 43 minutes with a cross clamp of 34 minutes. H... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> Penicillins / baclofen <ATTENDING> ___. <CHIEF COMPLAINT> shortness of breath <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ with bulbar ALS presenting with shortness of breath. The p... | [REDACTED] yo F with hx of bulbar ALS presenting with worsening shortness of breasth vs. anxiety. # SOB: Patient satted well overnight on continous oxygen monitoring. She was given ativan PRN for anxiety and used CPAP at night. Interventional Pulmonolgy physician was in room and stated no emergent need for trach. If pa... |
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<SEX> F <SERVICE> ORTHOPAEDICS <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ ___ Complaint: Right knee osteoarthritis <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: R TKR by ___, MD <HISTORY OF PRESENT ILLNESS> ___ year old femal... | 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... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> Penicillins / Erythromycin Base / Vancomycin <ATTENDING> ___. <CHIEF COMPLAINT> Dyspnea <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ with in USOH until 5 days ago when she developed... | 1. Asthma vs. reactive airways disease precipitated by viral URI. Improved tremendously by second day of admission with use of prednisone and inhalers. Discharged on 5 day course of prednisone and with prescription for new inhaler and spacer. 2. Hypertension/Hyperlipidemia. Continued home regimen |
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<SEX> M <SERVICE> CARDIOTHORACIC <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> dysphagia <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ 1. Esophagogastroduodenoscopy. 2. Minimally invasive ___ esophagectomy. 3. Buttressing of intrathoracic ana... | Mr. [REDACTED] was admitted to the hospital and taken to the Operating Room where he underwent an esophagogastroduodenoscopy, minimally invasive [REDACTED] esophagectomy and buttressing of intrathoracic anastomosis with thymic fat. He tolerated the procedure well and returned to the PACU in stable condition. He maintai... |
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<SEX> F <SERVICE> PSYCHIATRY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Bipolar disorder with manic symptoms off medications <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> From __... | PSYCHIATRIC: Ms. [REDACTED] was admitted on [REDACTED] with complaints of manic-like ssx (anxiety, insomnia, some paranoia) in setting of know Bipolar Affective Disorder Type 1 under treatment with outpatient psychiatrist Dr. [REDACTED] of [REDACTED]. She was restarted on lithium, aripipraole, and lorazepam as needed a... |
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<SEX> F <SERVICE> PLASTIC <ALLERGIES> latex / tree nuts / peanuts / adhesive tape <ATTENDING> ___. <CHIEF COMPLAINT> Left breast cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> s/p bilateral skin sparing mastectomies, L SLNB, and bilateral direct to impl... | [REDACTED] year old female with left breast cancer admitted s/p bilateral mastectomy with immediate implant reconstruction. She recovered well in the PACU and was transferred to the floor. Pain was well controlled and vital signs remained stable. Patient was able to ambulate to the bathroom and void without difficulty.... |
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<SEX> F <SERVICE> ORTHOPAEDICS <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> right knee pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: s/p complex right total knee replacement - totally stabilized <HISTORY... | 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> M <SERVICE> MEDICINE <ALLERGIES> morphine <ATTENDING> ___. <CHIEF COMPLAINT> cc: ___ pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> NONE <HISTORY OF PRESENT ILLNESS> This is a ___ y/o M with history of poorly controlled Type II diabetes, gastropares... | This is a [REDACTED] y/o M with history of poorly controled diabetes, hypertension and hyperlipidemia who presents with nausea, vomiting and abdominal pain. #Gastroparesis Admitted with abdominal pain similar to previous episodes. His abdominal exam was benign throughout the hospitalization. Treated with bowel rest, IV... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> somnolence <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> The patient is a ___ yoM w/ a h/o mood disorder, p... | ACUTE COPD EXACERBATION: Initially treated with IV solumedrol then PO prednisone at 40mg po daily for a total course of 5 days. He was also given doxycyline for a 7 day course, no infiltrate was seen on chest X ray (doxycycline was chosen given that he was on haldol for agitation and azithromycin could cause QTc prolon... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Diarrhea <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo F w/hx bloody diarrhe... | [REDACTED] with likely newly diagnosed ulcerative colitis admitted with recurrent bloody stools, abdominal pain and leukocytosis. This was felt to be consistent with an ulcerative colitis flare. She was originally started on ciprofloxacin and metronidazole for fevers and leukocytosis, which was discontinued after her s... |
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<SEX> F <SERVICE> SURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: Laparoscopic appendectomy <HISTORY OF PRESENT ILLNESS> ___ here with 24 hour... | Ms. [REDACTED] was admitted to the [REDACTED] with abdominal pain and OSH imaging showing acute appendicitis. She was given intravenous antibiotics in the ED and taken to the operating room where she underwent a laparoscopic appendectomy. For full details of the procedure, please see the separately dictated operative r... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> EtOH intoxication Possible Pneumonia <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ with alcoholism, chro... | [REDACTED] year old intoxicated male with history of multiple prior intoxication visits in ED presenting with acute intoxication complicated by patchy lingular opacity on CXR and Bilateral [REDACTED] swelling and erythema. # Possible Pneumonia: questionable whether patient has actual pneumonia given lingular opacificat... |
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<SEX> M <SERVICE> SURGERY <ALLERGIES> Gluten / Sodium Sulfate <ATTENDING> ___. <CHIEF COMPLAINT> Left calcaneal ulcer <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: LLE angiogram, L peroneal artery angioplasty <HISTORY OF PRESENT ILLNESS> This is an ___ y... | Patient was admitted to the vascular surgery service directly from clinic on [REDACTED]. Please refer to [REDACTED] for details of the initial presentation. Upon arrival to the floor, patient had normal vitals signs and laboratory values. Given the presence of an open ulcer on the left heel, he was started on empric IV... |
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<SEX> M <SERVICE> SURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> abdominal aortic aneurysm <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ ENDOVASCULAR ABDOMINAL AORTIC ANEURYSM REPAIR AND LEFT COMMON ILIA... | Mr. [REDACTED] is a [REDACTED] admitted to [REDACTED] who underwent endovascular abdominal aortic aneurysm repair on [REDACTED]. See operative note for details. The patient tolerated the procedure well. Vitals were stable, pain was well controlled, he tolerated a regular diet, was voiding spontaneously. He was stable f... |
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<SEX> M <SERVICE> UROLOGY <ALLERGIES> IV Dye, Iodine Containing <ATTENDING> ___. <CHIEF COMPLAINT> Right Renal Cell Carcinoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> Laparoscopic Right Radical Nephrectomy <HISTORY OF PRESENT ILLNESS> ___ w/ Waldenstroms... | Patient was admitted to Urology after undergoing laparoscopic Right radical nephrectomy. No concerning intraoperative events occurred; please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. The patient was transferred to the floor from the PACU in stable condition. On... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> SMA syndrome <MAJOR SURGICAL OR INVASIVE PROCEDURE> EGD ___ <HISTORY OF PRESENT ILLNESS> Patient is a ___ yo man with ?SMA s... | This is a [REDACTED] yo man with chronic abdominal pain who presents here with an acute exacerbation, along with nausea and vomiting. . # Chronic abdominal pain - The patient previously was thought to have SMA syndrome, however recent work-up in [REDACTED] was normal and not consistent with this syndrome. He has had pr... |
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<SEX> M <SERVICE> SURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Stage V Chronic Kidney Disease <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ living unrelated renal transplant <HISTORY OF PRESENT ILLNESS... | On [REDACTED], he underwent pre-emptive living unrelated renal transplant (left kidney to right external iliac artery an vein). A JJ ureteral stent and 19 [REDACTED] [REDACTED] drain were placed. CIT was 48min, WIT 28min. Surgeon was Dr. [REDACTED]. He received induction immunosuppression (ATG, Solumedrol and Cellcept)... |
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> decreased fetal movement and increased swelling <MAJOR SURGICAL OR INVASIVE PROCEDURE> repeat low transverse cesarean sec... | [REDACTED] y/o [REDACTED] admitted at [REDACTED] with preeclampsia. On admission, she had mild range elevated blood pressures and preeclampsia labs notable for an elevated urine protein/creatinine ratio (1.3). She was given a course of betamethasone for fetal lung maturity and seen by the NICU. Fetal testing was initia... |
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<SEX> F <SERVICE> NEUROSURGERY <ALLERGIES> ___ <ATTENDING> ___ <CHIEF COMPLAINT> Altered Mental Status <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ R suboccipital craniotomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo female with a history of metast... | Mrs. [REDACTED] was admitted to the neurosurgery service for altered mental status which was caused by hydrocephalus. Her hydrocephalus was in turn caused by a cerebellar metastasis of known cancer. She was brought to the neurosurgical ICU for close monitoring on [REDACTED]. On arrival to the ICU an EVD was placed for ... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Right foot pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Endotracheal intubation <HISTORY OF PRESENT ILLNESS> ___ year old woman recently... | MICU COURSE: Patient was admitted to the FICU due to concern for sepsis secondary to a UTI. She was started on pressors and aggressively fluid resuscitated. Patient was noted to be in atrial fibrillation with intermittent RVR. She was also profoundly delerious, which was thought to be multifactoral in etiology. When he... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> facial bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> EGD ___ <HISTORY OF PRESENT ILLNESS> Mr. ___ is a ___ male with history of alco... | Mr. [REDACTED] is a [REDACTED] male with history of alcohol cirrhosis complicated by ascites, portal hypertension listed for liver transplant, diffuse hidradenitis suppurativa, and remote C. difficile who presented as a transfer for anemia, with bleeding noted from multiple HS sites. ACUTE/ACTIVE ISSUES: ==============... |
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> hemorrhagic shock, liver injury <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ G1P1 with no... | BRIEF ICU COURSE ================= Patient transferred from [REDACTED] to the [REDACTED] ICU with concern for acute liver injury concerning for HELLP vs. shock liver in setting of recent post partum hemorrhage after vaginal delivery on [REDACTED]. She had no evidence of acute liver failure, and her transaminitis improv... |
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<SEX> M <SERVICE> CARDIOTHORACIC <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> TBM <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: tracheobronchoplasty <HISTORY OF PRESENT ILLNESS> ___ is a ___ w/ hx of TBM, CAD... | Mr. [REDACTED] presented to [REDACTED] as a same day admission for surgery on [REDACTED]. He was taken to the Operating Room where he underwent a tracheobronchoplasty. For full details of the procedure, please refer to the separately dictated Operative Report. He was kept in the ICU for monitoring until POD2 when he wa... |
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<SEX> M <SERVICE> SURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Bleeding after paracentesis <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ angiogram <HISTORY OF PRESENT ILLNESS> ___ man with a history of... | Mr. [REDACTED] is a [REDACTED] man who was transferred emergently from [REDACTED] for concerns of active bleeding after [REDACTED] guided paracentesis there. He was admitted to the surgical ICU, underwent [REDACTED] angiography which did not reveal any source of bleeding, and was supported throughout his hospitalizatio... |
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<SEX> M <SERVICE> SURGERY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Right ___ digit gangrene <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ Right leg angogram and ___ angioplasty <HISTORY OF PRESE... | Patient taken to the OR for an angiogram s/p Right [REDACTED] angio with [REDACTED] angioplasty. Post-operatively, the patient did well. He remained on bedrest for the appropriate time period. After bedrest, the patient ambulated without difficulties. There was no gross hematoma/pseudoaneurysmal formation noted on phys... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Ethylene glycol ingestion <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ with hx depression presenting a... | [REDACTED] w/ depression & hypothyroidism who presented for ethylene glycol overdose in a suicide attempt. She was initially admitted to [REDACTED], where her workup was notable for metabolic acidosis (but no renal failure), transaminitis, and a serum ethylene glycol level of ~1400. At that time she was started on IV f... |
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<SEX> F <SERVICE> SURGERY <ALLERGIES> Tape ___ / Morphine <ATTENDING> ___. <CHIEF COMPLAINT> Claudication <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ Iliac artery stent grafts x2. <HISTORY OF PRESENT ILLNESS> ___ year old female with a history of corona... | Pt was admitted for the proposed procedure through the cardiology service. During the procedure of stenting her right external iliac the vessel ruptured. Vascualr surgery was consulted during the case. She underwent s/p stent graft repair with 2X covered stents. During the procedure she had a transient episode of hypot... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> Penicillins / Morphine <ATTENDING> ___. <CHIEF COMPLAINT> left sided abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> This is a ___ year old female with PMH of polysubstance ... | This is a [REDACTED] year old female with PMH of polysubstance abuse, poorly controlled DM2, spinal paralysis secondary to a gun shot wound, wheelchair bound with a neurogenic bladder, indwelling Foley, and bowel incontinence, who presented with left sided flank/abdominal pain for 5 days likely secondary to constipatio... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> Shellfish Derived <ATTENDING> ___ <CHIEF COMPLAINT> Right shoulder pain with deep respiration <MAJOR SURGICAL OR INVASIVE PROCEDURE> None. <HISTORY OF PRESENT ILLNESS> ___ yo man with PMH of asthma p/w chief compl... | Mr. [REDACTED] is an [REDACTED] yo man with PMH of asthma p/w fevers, pleuritic shoulder pain, productive cough, SOB with cough, night sweats and malaise x 4days, found to have cavitary lesion on chest x-ray. . # Shortness of breath, cough and fever: Pt reported progressive cough, pleuritic pain, SOB and fevers x 4days... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> Aspirin / Iodine / Nsaids / Opioids-Morphine & Related <ATTENDING> ___ <CHIEF COMPLAINT> Abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Interventional radiology - pelvic fluid collection drainage <HISTORY OF... | Appendicitis: The patient was admitted to the General Surgical Service on [REDACTED] for evaluation and treatment of abdominal pain after a recent laparoscopic appendectomy. Admission abdominal/pelvic CT revealed a pelvic fluid collection, WBC was not elevated. She was started on IV antibiotics. The patient underwent d... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> Demerol / Depo-Provera / Promethazine <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> This is a ___ y/o female with chronic pancreatitis, ... | [REDACTED] y/o female with chronic pancreatitis and the above medical history, who presents with acute on chronic abdominal pain, consistent with prior chronic pancreatitis flares. . Problems: # Chronic pancreatitis: Recurrent presentations requiring hospitalization. Outpatient GI, Dr. [REDACTED], was notified. Patient... |
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<SEX> M <SERVICE> MEDICINE <ALLERGIES> ACE Inhibitors / doxycycline / Bactrim <ATTENDING> ___. <CHIEF COMPLAINT> Abd Pain, Diarrhea <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Pt is an ___ y/o M with PMHx of CAD and AS s/p ... | On admission, Mr. [REDACTED] was noted to have a CT scan consistent with a Crohn's flare, as well as continual diarrhea and abdominal pain. A C Diff was negative, CRP was elevated above his baseline, and a stool culture was sent, which is no growth to date. His vital signs were stable. Gastroenterology was consulted, w... |
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<SEX> M <SERVICE> CARDIOTHORACIC <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Right lower lobe nodule <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ Bronchoscopy, Right VATs, Right lower lobe superio... | Mr. [REDACTED] was admitted on [REDACTED] and underwent successful bronchoscopy, thoracoscopy video-assisted right lower lobe wedge resection, right lower lobe segmentectomy, mediastinal lymph node dissection. He was extubated in the operating room, monitored in the PACU prior to transfer to the floor. He had a anterio... |
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<SEX> M <SERVICE> CARDIOTHORACIC <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Chest Pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ - Coronary artery bypass graft x3: Left internal mammary artery to left ant... | [REDACTED] was admitted on [REDACTED] and was taken to the operating room. He underwent coronary artery bypass grafting x 3. Please see operative note for full details. He tolerated the procedure well and was transferred to the CVICU in stable condition for recovery and invasive monitoring. He weaned from sedation, awo... |
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<SEX> F <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> WEAKNESS <MAJOR SURGICAL OR INVASIVE PROCEDURE> NONE <HISTORY OF PRESENT ILLNESS> ___ w/ hx CKD s/p transplant ___, DM, HLD, HTN, OSA,... | [REDACTED] year-old woman with a history of cadaveric renal transplantation with CKDIII, with a new diagnosis of adenocarcinoma of the lung with a wedge resection of [REDACTED], who presented with shortness of breath, fever, and DKA. She was treated with an insulin drip and transferred to the medicine floor. She had a ... |
Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> Lipitor / Pravachol / Penicillins / Percocet / Codeine <ATTENDING> ___. <CHIEF COMPLAINT> ARF and hyperkalemia <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo F noted to have ARF an... | PATIENT: [REDACTED] yo F DM, HTN and h/o MI in [REDACTED] (normal EF), admitted for hyperkalemia and acute renal failure. ACUTE: # Acute renal failure - Creatinine on admission was 1.7, up from a baseline of 1.1. In discussions with the patient, it was determined that her PO intake had been poor over the last few weeks... |
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