EXAMPLE Anuradha Chirala, M.D. DISCHARGE SUMMARY ________________________________ 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.