Discharge Summary Samples printable pdf download

Discharge Summary Samples

DISCHARGE DIAGNOSES:

Acute anterior wall myocardial infarction.

Two-vessel coronary artery disease.

Ischemic cardiomyopathy with an ejection fraction of approximately 45%.

Hypercholesterolemia.

Smoker.

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