EXAMPLE
Anuradha Chirala, M.D.
DISCHARGE SUMMARY
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DISCHARGE DIAGNOSES:
1.
Status post atrial fibrillation.
2.
Status post congestive heart failure.
3.
Severe dilated cardiomyopathy.
4.
Moderate-to-severe three-vessel coronary artery disease.
5.
Hypertension.
6.
Hyperlipidemia.
HISTORY OF PRESENT ILLNESS: Please see admit note for complete
details. In brief, the patient is a 45-year-old white male who
woke up with the sudden onset of shortness of breath and
respiratory distress and came to the emergency room. In the
emergency room, the patient was noted to be in rapid atrial
fibrillation with a heart rate of 160-170. The patient was
immediately started on Cardizem bolus and drip, and his heart
rate got better.
HOSPITAL COURSE: The patient was admitted to the ICU with a
diagnosis of rapid atrial fibrillation and congestive heart
failure. BNP was 555. The patient was recently in VMC for
congestive heart failure and dilated cardiomyopathy. The patient
had undergone cardiac catheterization at VMC and was apparently
noticed to have severe three-vessel disease with 70% distal left
anterior descending (LAD) lesion, 90% proximal obtuse marginal-3
(OM-3) lesion, and 70% mid-right coronary artery (RCA) lesion.
The patient also had a nuclear scan, which revealed ischemia in
anterior and inferior walls, and an left ventricular ejection
fraction (LVEF) of 20% with moderate-to-severe mitral
regurgitation. The patient was not revascularized and it was
decided he would be managed medically. During the hospital
course, the patient was also started on IV digoxin 0.125 mg IV
every 6 hours and was digitalized and also IV Cardizem 5 mg,
which was discontinued. Atrial fibrillation (afib) rate became
very controlled. The patient had no complaints of chest pain or
shortness of breath during the hospital course. The patient was
ruled out for acute MI with negative CPKs, enzymes, and
troponins. The patient remained hemodynamically stable and was
restarted on all of his medications, including Coreg, Coumadin,
and Lasix. The patient had a dry, constant cough, which was
found to be secondary from Monopril, and that was discontinued.
IV Cardizem was discontinued, and the patient was changed to p.o.
Cardizem. Several attempts were made to transfer the patient to
VMC for vascularization, because I strongly felt the patient was
having PND, which was equal to angina, and in view of ischemia
and three-vessel disease, the patient would benefit from
revascularization. Several attempts were made to transfer the
patient to VMC, but the patient was refused to be transferred
there, as he was not a resident of Santa Clara County. The
patient clinically improved, had no further angina or congestive
heart failure. He remained hemodynamically stable, and heart
rate was well controlled in the 80s. The patient is presently
being discharged home on Coreg 6.25 mg b.i.d., digoxin 0.125 mg
once a day, Coumadin 8 mg a day, Cardizem 30 mg p.o. every 8
hours, Lasix 20 mg a day, and Diovan 40 mg a day.
CONDITION OF PATIENT AT TIME OF DISCHARGE:
Stable.
DISCHARGE INSTRUCTIONS: The patient has been instructed to quit
smoking and to be compliant with his medications. The patient
has also been instructed to follow up with VMC on Monday, as he
already has an appointment there and to follow up with the
Coumadin clinic. All of the above has been explained to his mom.
I had a talk with the mother also that the patient would need
revascularization.