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Cardiac Discharge Summary Transcribed Medical Transcription Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY

ADMITTING DIAGNOSES:
1.  Coronary artery disease, ischemic cardiomyopathy.
2.  Systolic congestive heart failure.
3.  Chronic cholecystitis.

CHIEF COMPLAINT:  Shortness of breath.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male with significant cardiac history.  History of a STEMI with LAD stenting and an ICD placement for ischemic cardiomyopathy.  The patient presented complaining of chest tightness, fatigue, and increasing shortness of breath.  The patient stated that he was compliant with his medications but stated, at the time of admission, that he had increased intake of salty food and then noticed that he had increased edema up to his thigh.  He is complaining of orthopnea and shortness of breath, especially on activity.  The patient also is complaining of shortness of breath when lying down.  The patient denied any chest pain or any palpitations at the time of admission.  Denied any fever or any chills.  The patient did state that he has a chronic cough with clear sputum.  He also states that he is able to walk and climb a flight of stairs without any significant shortness of breath.  Upon admission in the ER, he was given Lasix 60 mg IV and nitroglycerin paste 1 inch.

PAST MEDICAL/SURGICAL HISTORY:  History of coronary artery disease, had a STEMI status post stent placement to the LAD, ischemic cardiomyopathy with a systolic CHF, underwent ICD placement, pericardial effusion with a tamponade for which he underwent a pericardial window, chronic cholecystitis and history of acute renal failure.

FAMILY HISTORY:  History of coronary artery disease with father undergoing a coronary artery bypass.

SOCIAL HISTORY:  The patient denies any smoking, alcohol or any IV drugs.

REVIEW OF SYSTEMS:  At the time of admission, the patient did complain of some fatigue and chronic cough with clear sputum.  Denies any fever, chills or any chest pain or any shortness of breath at the time of admission.  The patient denies any abdominal pain, nausea or vomiting or any GI symptoms.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

PHYSICAL EXAMINATION:
VITAL SIGNS:  At the time of admission, the patient's temperature is 98.4, blood pressure 126/94.  The patient was saturating 94-100% on room air.  Heart rate was 86.
In the ER, the patient's urine output was 950 mL.
GENERAL APPEARANCE:  The patient was in no apparent distress.  Was alert and oriented.
HEENT:  Pupils are equal, round, and reactive to light and accommodation.
NECK:  Positive JVD.
LUNGS:  Bilateral crackles were present.
HEART:  Regular rate and rhythm.  S1, S2 normal.
ABDOMEN:  Soft with mild diffuse tenderness.  Murphy sign was negative.  No organomegaly and bowel sounds are present.
EXTREMITIES:  3+ edema up to the upper thighs.
NEUROLOGIC:  No focal deficits present.

LABORATORY DATA:  At the time of admission, the patient's sodium was 137, potassium 4.2, chloride 102, CO2 of 26, BUN 16, creatinine 1.2, glucose 96, calcium 9.2, phosphorus 3.7, magnesium 1.8, bilirubin 2.7, AST/ALT were 24 and 17.  Troponin was 0.01.  BNP was 3700.  Triglycerides 56, cholesterol 129, LDL 93, HDL 25.  Alkaline phosphatase 170.

HOSPITAL COURSE AND TREATMENT:  The patient was admitted to the cardiology service and the plan was to have the patient admitted and to rule out acute coronary syndrome.  Troponins were cycled x3, which were negative.  The plan was to continue Lipitor, Coreg, Plavix, Lasix, Aldactone and continue on the Coumadin.  The plan was to diurese the patient and also to have the patient undergo a 2-D echo.  A 2-D echo was done which showed marked cardiomyopathy with an ejection fraction in the range of 15%, which was associated with marked left ventricular dilatation, moderate mitral regurgitation and mild to moderate pulmonary hypertension.  No pericardial effusion, no pleural effusion present.  It showed anteroseptal and apical akinesis with generalized hypokinesis and with a small segment of relatively intact motion in a high posterior wall.  During the patient's hospitalization, we were continuing to diurese the patient and the patient was asymptomatic.  Denied any shortness of breath or any chest pain or palpitations and was hemodynamically stable.  The plan was to continue on all of the patient's home medications.  The patient has history of chronic cholecystitis.  It was scheduled for the patient to follow up with General Surgery, but the patient did not comply with the appointment made for him.  So, at the time of admission, the patient's bilirubin was 2.9, and the plan was to have the patient undergo an ultrasound.  The ultrasound report stated that there was a cyst in the region of the porta hepatis/the gallbladder fossa.  This cyst appeared to be a simple cyst, which measured approximately 5 cm in maximal cross-sectional diameter.  There was no evidence of intra and extrahepatic ductal dilatation.  The patient was informed about the finding on the ultrasound but stated that he would like to go home on the day of discharge.  The patient was able to tolerate regular diet during his admission and stated that he would want to leave the hospital even though it was recommended that a general surgery consult should be obtained.  Even with information given to the patient, the patient stated that he would rather follow up with General Surgery as an outpatient.

CONDITION AT DISCHARGE:  The patient was medically and hemodynamically stable for discharge.  The patient was told about the elevated LFTs and ultrasound results; however, the patient stated that he would like to go home and that he would rather follow up with General Surgery as an outpatient.

DISCHARGE INSTRUCTIONS:  The patient was instructed that if he develops any fever, chills, chest pain, shortness of breath or any abdominal pain that the patient must report to the emergency room right away.  The patient was instructed to follow a cardiac, low-salt diet.  The patient was also to follow up at the primary health clinic and appointment was made.  Also, a cardiology clinic appointment was made for the patient and an appointment was made at the general surgery clinic for his history of chronic cholecystitis and elevated LFTs.  Also, the patient is to follow up with the Coumadin clinic.

DISCHARGE MEDICATIONS:  Plavix 75 mg p.o. daily, Prilosec 20 mg p.o. daily, trazodone 50 mg p.o. at bedtime, Coumadin 2.5 mg p.o. at bedtime, carvedilol 12.5 mg p.o. b.i.d., Lasix 40 mg p.o. b.i.d., and Aldactone 25 mg p.o. b.i.d.

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