Discharge Summary Samples (Page 2 of 6) in pdf

Discharge Summary Samples

DIAGNOSIS: Endometrial cancer.

SURGERY PERFORMED: Total abdominal hysterectomy, bilateral salpingo-

oophorectomy, 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 3

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:

Unstable angina.

Coronary artery disease status post stenting.

Hypothyroidism.

Hyperlipidemia.

Hypertension.

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

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