| [ | |
| { | |
| "prompt": "[DISCHARGE | 2150-06-01 12:00]\nChief Complaint: chest pain\n\nHistory of Present Illness: ", | |
| "generation": "\nMr. ___ is a ___ male with h/o CAD s/p MI, HTN, and DM who \npresents with chest pain. He was recently admitted to ___ for \nchest pain, and he underwent a stress test which was negative. He \nwas discharged on ___. Since then, he has been experiencing \nintermittent chest pain similar to his prior presentation. The \npain is described as substernal and radiating to his left arm. \nIt has been occurring over the past several days, lasting \napproximately 10 minutes, and is associated with nausea and \ndiaphoresis. He denies any SOB or dizziness. He was seen by his \nPCP this morning, and was referred to the ED. \nIn the ED, initial vitals were T 97.6, HR 86, BP" | |
| }, | |
| { | |
| "prompt": "[RADIOLOGY | 2150-06-02 09:30]\nEXAMINATION: CHEST X-RAY\nINDICATION: shortness of breath\nFINDINGS: ", | |
| "generation": "\n\nSingle portable upright AP view of the chest.\n\nCompared to prior study from ___ there has been no significant\ninterval change.\n\nLow lung volumes are noted. The lungs are clear. There is no pleural\neffusion, pneumothorax or focal consolidation. The heart size is normal. \nThe mediastinal and hilar contours are unremarkable. No acute osseous\nabnormalities identified.\nIMPRESSION: \n\nNo acute cardiopulmonary process." | |
| }, | |
| { | |
| "prompt": "[DISCHARGE | 2150-06-03 08:00]\nBrief Hospital Course:\nThe patient was admitted for ", | |
| "generation": "ileostomy reversal. Preoperatively, he \nwas given a bowel prep. He was taken to the operating room on \n___ and underwent an ileostomy reversal. Please see the \noperative report for further details. He tolerated the procedure \nwell and was extubated upon completion. He was then transferred \nto the PACU for recovery. He was later transferred to the floor \nfor further recovery. On POD 1, he was noted to have an ileus \nand had difficulty passing flatus. An abdominal xray was done \nwhich did not show obstruction. He was started on an aggressive \nbowel regimen and had an improvement in his symptoms. His diet \nwas advanced to regular which he tolerated well. On POD 2, he \nwas noted to be passing gas and stool. He was discharged home \n" | |
| } | |
| ] |