SAMPLE
O'CONNOR HOSPITAL
DISCHARGE SUMMARY
DVI WORK TYPE: 44
ROD WORK TYPE: DS
DICTATOR: R. PASCUA, ID# 501172
DISCHARGE DIAGNOSES:
1. Pneumonia, improved.
2. Atrial fibrillation, ventricular rate controlled.
3. Congestive heart failure, compensated.
4. Hypertension.
5. History of multiple myeloma.
6. Diabetes mellitus secondary to medication of steroid,
Decadron, for more multiple myeloma.
HISTORY OF PRESENT ILLNESS: The patient was admitted on
05/21/2003 complaining of generalized weakness, shortness of breath, no chest pain, and no palpitations. He denies any fever or any chills, but complains of mild productive cough. He was seen in the emergency room where a chest x-ray was done, which showed cardiomegaly, no interstitial pulmonary edema, but with a right upper lobe pneumonia.
The patient was subsequently started on IV antibiotics.
HOSPITAL COURSE:
1. Pneumonia: The patient was started on intravenous
Claforan together with azithromycin. His white count had been stable, and he remained afebrile. He was put on oxygen supplementation, two liters, in which he subsequently discontinued because of improvement of his symptoms. He was switched to oral Levaquin with no untoward reactions and also had improvement of his symptoms. He also remained afebrile throughout the hospitalization.
2. History of atrial fibrillation: He has been taking
Coumadin for this and his PT and INR have been at therapeutic levels.
3. Hypertension: The patient has been taking Lotensin
5 mg p.o. b.i.d. On this admission, the patient's dose was increased to 10 mg p.o. b.i.d.

4. History of congestive heart failure: The patient had been on Coreg 6.25 mg p.o. b.i.d. and with an addition of Lasix 40 mg p.o. b.i.d.
5. History of multiple myeloma: The patient had been followed up by Dr. Peggy Lu for this.
6. Diabetes mellitus: The patient's fingersticks have been closely followed up. He was put on regular sliding scale.
CONSULTATIONS: None.
COMPLICATIONS: None.
ACTIVITY: The patient can do physical activity as tolerated.
DIET: The patient can resume his diabetic diet, 1800 kilocalorie.
DISPOSITION: The patient will go home today with his wife.
MEDICATIONS:
1. Coreg 6.25 mg p.o. b.i.d.
2. Lotensin 10 mg p.o. b.i.d.
3. Coumadin 2.5 mg p.o. q.d.
4. Digoxin 0.25 mg p.o. q.d.
5. Lasix 40 mg p.o. b.i.d.
6. Zithromax for five days.
7. Levaquin 500 mg p.o. q.d. for 10 days.
FOLLOW-UP CARE: The patient was instructed to see his primary care provider, Dr. Bommakanti Rani, and has a scheduled appointment on Wednesday.
The patient's wife and the patient have been instructed that if he develops any shortness of breath, any coughing, any fever, or any chills, he is to call his primary care provider or seek emergent medical attention.