SUTTER COAST HOSPITAL
EXAMPLE - DISCHARGE SUMMARY, Steven Slack, M.D.
REASON FOR ADMISSION:
Dyspnea and fever.
DISCHARGE DIAGNOSES:
1. Pneumonia, NOS.
2. Bronchospasm.
3. Hypothyroidism.
4. Hypertension.
5. Dementia.
SIGNIFICANT EVENTS AND HOSPITAL COURSE: The patient is a
92-year-old nursing home resident who was brought to the
emergency room because of dyspnea and a low-grade
temperature. She had been wheezing throughout much of the
day and by report had an increasingly productive cough over
the three days prior to her admission. Her son who was
visiting her decided to bring her to the emergency room.
In the ER she was flushed, mildly breathless, and
complained of dyspnea.
Initial laboratory assessment showed possible faint right
lower lobe infiltrates in the area of the right inferior
pulmonary artery. Leukocytosis was 12,000, H&H 11/34 with
essentially normal platelet count and differential. Her
blood sugar was 235, creatinine 1.2, BUN 26.
In the field diagnostic impression was a possible
pneumonia, anemia, and hyperglycemia.
She was admitted to the medical/surgical ward. Sputum,
blood, and urine cultures were undertaken. The sputum Gram
stain was unremarkable. She was started on Levaquin 500 mg
intravenously, received supplemental oxygen. Serial blood
sugars were undertaken and were treated with regular
insulin sliding scale, mild intensity.
She gradually improved. She became more alert, although
she has a mild dementia at baseline.
She is discharged now in improved condition.
DISCHARGE MEDICATIONS: Prednisone 40 mg daily for 7 days,
Levaquin 500 mg daily for 7 days, Synthroid 50 mcg daily,
albuterol med nebulizer q.4 hours p.r.n. or albuterol 4
puffs q.i.d. by metered dose inhaler with a spacer,
depending on patient preference, Protonix 40 mg daily for 7
days, lisinopril 10 mg daily, milk of magnesia 30 mg
t.i.d., regular diet. Aspirin 81 mg daily.
She will return to the nursing home. I spoke with her son,
who confirmed the patient's advanced directives and that we
do not intubate and no not resuscitate in the event of
cardiopulmonary arrest.