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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... |
Summarize or extract clinical findings from the following EHR note:
<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... |
Summarize or extract clinical findings from the following EHR note:
<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 ... |
Summarize or extract clinical findings from the following EHR note:
<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... |
Summarize or extract clinical findings from the following EHR note:
<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... |
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