Discharge Summary Samples
DISCHARGE DIAGNOSES:
1. Acute anterior wall myocardial infarction.
2. Two-vessel coronary artery disease.
3. Ischemic cardiomyopathy with an ejection fraction of approximately 45%.
4. Hypercholesterolemia.
5. Smoker.
6. Family history of coronary disease.
PROCEDURES: On 03/18/2004 the patient underwent emergent cardiac
catheterization. The study showed an ejection fraction of 45% with anterolateral and
apical akinesis and mild mitral regurgitation. The patient had a 90% proximal left
anterior descending artery stenosis with thrombus as well as a 20% mid left anterior
descending artery stenosis. There is a 20% to 30% proximal circumflex lesion. A large
branching obtuse marginal had a 70% stenosis at its bifurcation. The proximal RCA
had a 30% to 40% stenosis of mild diffuse disease. The patient underwent PCI of the
left anterior descending artery with a 3.0 x 18 mm Cypher stent with 0% residual
stenosis and TIMI III flow.
DISCHARGE MEDICATIONS: Zocor 40 mg q. d., aspirin 81 mg q. d., Plavix 75 mg q.
d., Coreg 3.125 mg q. d. and Detrol LA 4 mg q. d.
HOSPITAL COURSE: The patient presented to the emergency room on 03/18/2004
with complaints of chest pain and EKG findings of acute anterior wall myocardial
infarction. She was brought emergently to the catheterization laboratory with findings
as above. After intervention she had no further chest pain concerning for angina.
The patient was started on the usual post myocardial infarction medications including
and ACE inhibitor and beta-blocker. With these medications she became quite
hypotensive with systolic pressures in the 70s. The medicines were held and with IV
fluids her blood pressure increased to a baseline systolic in the 90s to low 100s. Coreg
is now being re-instituted at a very low dose (3.125 mg now b.i.d.).
The patient was otherwise feeling well with no dizziness, lightheadedness or syncope
and no complaints of dyspnea. She was walking up in the halls without difficulty. On
03/22/2004 she was feeling well and was discharged to home.
DISCHARGE INSTRUCTIONS AND FOLLOW UP: The patient will continue with
medications as above. We are arranging follow up for her on Friday, 03/26/2004 before
she returns to Michigan. We will obtain a surface echocardiogram this week in our
office to assess her LV function post intervention and rule out any significant valvular
disease. She should do no lifting for the next several days and after returning home she
should enroll in a cardiac rehabilitation program. We discussed the critical importance
of smoking cessation and she does seem motivated to remain tobacco free. We also
discussed the importance of a low fat, low cholesterol diet.
Discharge Summary Samples
DIAGNOSIS: Endometrial cancer.
SURGERY PERFORMED: Total abdominal hysterectomy, bilateral salpingooophorectomy, omentectomy and pelvic lymph node dissection.
HISTORY: The patient is a 63-year-old female who was admitted on 03/19/2004 for the
above surgery. She was originally to have a laparoscopic assisted vaginal
hysterectomy and bilateral salpingo-oophorectomy and pelvic lymph node dissection, but
upon inspection of the pelvis, the patient had a tumor fungating through the fundus of the
uterus and it was felt not safe to perform an laparoscopic assisted vaginal hysterectomy
so we performed an open laparotomy.
Postoperatively the patient has done well and has progressed without complication. On
her 3rd postoperative day she has had bowel function. She is tolerating a regular diet.
Hemoglobin is stable at 8.5 and she is ready for discharge. She will be discharged
home and will return to the office in 10 days for staple removal and see me in the office
in two weeks to discuss pathology results. She will be sent home on Percocet 5/325.
Discharge Summary Samples
ADMISSION AND DISCHARGE DIAGNOSES:
1. Unstable angina.
2. Coronary artery disease status post stenting.
3. Hypothyroidism.
4. Hyperlipidemia.
5. Hypertension.
6. History of myocardial infarction.
PROCEDURE S: Percutaneous transluminal coronary angioplasty of the left anterior
descending artery, cardiac catheterization.
HISTORY AND HOSPITAL COURSE: The patient is an 82-year-old female that had an
anterior myocardial infarction in October of 2003 and underwent stenting of the left
anterior descending artery with several stents. She had a bifurcation and a lesion at the
diagonal branch and had to have multiple stents placed.
She had done well over the past several months until the past week when she started
having recurrent episodes of an atypical type chest pain. She underwent a nuclear
exercise test in her internist's office and this was consistent anterior ischemia and she
did have angina during the stress test. The patient was directly admitted to the
telemetry unit and placed on Lovenox, nitrates and did rule out for myocardial infarction.
The following day she underwent a cardiac catheterization, which showed in stent
restenosis of the stent near the bifurcation of the diagonal branch. These stents were
then dilated to a larger size to 2.5 having had been 2.25 stents. There was still a
residual stenosis at the diagonal branch, but this was not addressed due to the risk of
recurrent in stent restenosis in the left anterior descending artery. An Angio Seal
hemostatic device was placed. However, this failed and she did have bleeding after the
catheterization and had to have a FemoStop placed. Despite this her hemoglobin did
remain stable, dropping only from 11.3 to 10.0.
It was also noted that she had an incomplete right bundle branch block on her ECG the
following day therefore she was kept in the hospital and additional day and ambulated.
A baseline ECG then did return to normal and she had no elevation of her enzymes.
She was discharged home in stable condition and will be followed up in my office in four
weeks.
DISCHARGE MEDICATIONS: Plavix 75 mg per day, Lotensin 20 daily, aspirin 81 daily,
Synthroid 0.5 q. d., Toprol XL 100 q. d., Zocor 40 q. d., sublingual nitroglycerin p.r.n.,
Neurontin 300 daily, Bextra 20 mg daily, Ambien p.r.n., Actonel 35 weekly, Imdur 30 mg
q. d.
Discharge Summary Samples
ADMISSION DIAGNOSES:
1. Gastrointestinal bleed.
2. Anemia.
DISCHARGE DIAGNOSES:
1. Antral arteriovenous malformations.
2. Sigmoid arteriovenous malformations.
3. Diverticulosis, chronic.
4. Internal hemorrhoids.
5. Resulting anemia.
6. Chronic lung disease.
7. Diabetes.
8. Coronary artery disease.
9. Gastroesophageal reflux disease.
10. Hypertension.
11. Hypothyroidism.
12. Dyslipidemia.
13. Cardiac arrhythmia.
14. Cholecystectomy.
15. Tubal pregnancy rupture.
16. Perforated ulcer.
HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old lady who presented on
the 27th and was admitted by Dr. Wolper secondary to melena and weakness. She was
anemic.
HOSPITALIZATION COURSE: The patient was admitted to the medicine service. She
underwent an enteroscopy on the 28th revealing a gastric prepyloric AVM and a
colonoscopy on the 29th of February revealing sigmoid AVM, diverticulosis and chronic
internal hemorrhoids that were successfully ablated.
The patient is doing well and her laboratories on the 29th were a white count of 7.3,
hematocrit of 29.5, platelets 166,000. She underwent colonoscopy without event and
she is ready to be discharged.
DISCHARGE MEDICATIONS: Same as above, avoid anticoagulation therapy for now
and NSAID and continue diabetic diet and a cardiac diet.
FOLLOW UP: In the office for a video enteroscopy.
CONSULTANTS: None.
PROCEDURES: Enteroscopy and colonoscopy.
ACTIVITIES: Ad lib. Watch out for symptoms of recurrent gastrointestinal bleeding.
Discharge Summary Samples
FINAL DIAGNOSES:
1. Intrauterine pregnancy past date.
2. Failure to progress.
3. Primary cesarean section.
4. Viable baby boy with Apgars of 9 and 9 and weight of 11 pounds.
DISCHARGE SUMMARY: The patient is a 37-year-old Haitian female, gravida 3, para 2
with an estimated date of confinement of February 16th, admitted on February 25th in
labor. The patient was followed by the midwife. Eventually, because of failure to
progress on February 26th, the patient was taken for primary cesarean section by Dr.
Skinner. A viable baby boy with Apgars of 9 and 9 and a weight of 11 pounds was
delivered.
Postpartum course was unremarkable and the patient was discharged on February 29th
to be followed in the office by Dr. Skinner. At the time of discharge the staples were
removed. The patient was afebrile and was passing flatus.
Admission hemoglobin was 12.9, hematocrit 36.8. On February 27th hemoglobin was
9.2 and hematocrit 26.3. Blood type is A negative. The baby was negative and for that
reason no RhoGAM was given. The patient was discharged February 29th to be
followed in the office by Dr. Skinner. A prescription for Percocet #30 tablets and Feosol
to take b.i.d. was given.
Discharge Summary Samples
ADMITING DIAGNOSES:
1. Acute exacerbation of chronic obstructive pulmonary disease with hypoxia.
2. Acute bronchitis.
3. History of tobacco abuse.
4. Accelerated hypertension.
5. History of cerebrovascular accident.
FINAL DIAGNOSES:
1. Acute exacerbation of chronic obstructive pulmonary disease with hypoxemia,
improved.
2. Acute bronchitis, improved.
3. History of tobacco abuse.
4. Accelerated hypertension, improved.
5. History of stroke, stable.
HOMEGOING INSTRUCTIONS: This patient is discharged in afebrile, stable,
satisfactory condition. She is still having a cough, but air exchange is much better.
Chronic obstructive pulmonary disease is about 93% improved and we have the OK
from cardiology and pulmonology to discharge. She will have a 2-D echocardiogram
and cardiac workup outpatient. She is to follow up with the cardiologist for this and she
will follow up with the pulmonologist. Her main stay is to quit smoking. She has been
emphasized this several times and she is quite aware that if she continues in this mode
it would definitely shorten her life or cause her death.
At this point in time discharge orders are as follows:
1. She is to follow up with me in the office in two weeks.
2. She is to follow up with the pulmonologist and cardiologist as per their instructions.
3. Her diet is as before.
4. Activity, slowly increase as tolerated. No smoking.
DISCHARGE MEDICATIONS: Include tapering dose of prednisone as per the
prescription. It will be 10 mg prednisone one p.o. daily times three days then ½ tablet
p.o. daily times three days then discontinue. Zithromax 500 mg one daily times eight
days. Advair Diskus one puff b.i.d. using spacer, Prinivil 5 mg one daily, Lasix 40 mg
one daily, Lopressor 25 mg one b.i.d., Combivent inhaler two puffs b.i.d. with spacer,
Micro-K 10 mEq one daily, enteric coated aspirin 81 mg daily, Protonix 40 mg one daily
while on prednisone and Tussionex 6 ounces one teaspoon every 12 hours for cough.
She is to use spacer with the MDI.
This 78-year-old female was admitted to the emergency room complaining of worsening
shortness of breath over the past three to four weeks. The patient was brought to Lee
Convenient Care for evaluation and transferred over to the emergency room.
PHYSICAL EXAMINATION: In the emergency room this is a thin 78-year-old white lady
whose apparent age is equivalent to chronologic age, very pleasant, cooperative, no
acute distress. VITAL SIGNS: Blood pressure on arrival is 207/77 going down to
149/56 when evaluated. Pulse was 87, respiratory rate 20. The patient is afebrile.
HEENT: Was within normal limits. NECK: Supple. No lymphadenopathy, cervical or
supraclavicular noted. CHEST: Lungs have occasional wheeze. Good breath sounds
noted in the bases. HEART: Has normal S1, S2, regular rate and rhythm.
ABDOMEN: No hepatosplenomegaly. No guarding or rigidity. Soft and nontender
without rebound. Bowel sounds are present in all four quadrants. EXTREMITIES: Full
range of motion noted in all four extremities. No cyanosis, clubbing, or edema noted.
2+ pulses noted in all four extremities. NEUROLOGIC: Cranial nerves are intact and
grossly nonfocal.
TEST RESULTS: Chest x-ray did not reveal any acute infiltrates. Blood gas at room air
revealed a pH of 7.345, CO2 was 43.7, pO2 was 46.6 with a saturation at 80.9%.
LABORATORY DATA: Shows a blood chemistry including liver function test within
normal limits. CBC was within normal limits. EKG study revealed normal sinus rhythm
with multiple PVCs and possible right atrial enlargement. ST T wave anomalies were
noted throughout.
HOSPITAL COURSE: This patient was admitted to telemetry and Dr. Conrado of
pulmonology was consulted along with cardiology. There were some thoughts that this
patient also may have some underlying congestive heart failure probably brought on by
her chronic obstructive pulmonary disease.
She was given Solu-Medrol 125 mg IV, Vasotec 1.25 mg IV and Norvasc 5 mg p.o. She
was placed on O2 nasal cannula at three to four liters per minute. She was continued
on prednisone IV, which was then changed to p.o. and started her wean. She was also
started on IV Zithromax along with some Protonix. Lasix was included daily along with
Combivent inhaler, nebulizer updrafts and Advair Diskus. Because of her being slightly
tachycardic they added in Lopressor and that appeared to bring her pulse down nicely.
Her Prinivil was at the same time decreased to 5 mg a day. She was put on Tussionex
for cough control.
She slowly continued to improve with aggressive respiratory treatment and therapy and
was discharged.