Medical Transcription Discharge Summary Sample #2:
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMITTING DIAGNOSIS: Syncope.
CHIEF COMPLAINT: Vertigo or dizziness.
HISTORY OF PRESENT ILLNESS: This is an(XX)-year-old male with a past medical history of coronary arterydisease, CABG done a few years ago, atrial fibrillation, peripheralarterial disease, peripheral neuropathy, recently retired one yearago secondary to leg pain. The patient came to the ER for anepisode of vertigo while reaching for some books. The patient wasable to reach the books, to support self, but did not have anysyncope. No nausea or vomiting. No chest pain. No shortness ofbreath. Came to ER and had a CT head, which was within normallimits. The impression was atrophy with old ischemic changes but noacute intracranial findings. No focal weakness, headache, visionchanges or speech changes. The patient has had similar episodessince one year. Peripheral neuropathy since one year and notrelieved with multiple medications. The patient also complains ofweight loss of 25 pounds in the last 6 months. No colonoscopy done.Recent history of hematochezia but believes it was secondary toproctitis and secondary to decreased appetite. No nausea, vomiting,no abdominal pain.
PROCEDURES PERFORMED: The patient had a chestx-ray, which showed cardiomegaly with atherosclerotic heartdisease, pleural thickening and small pleural effusion, a leftcostophrenic angle which has not changed when compared to priorexamination, COPD pattern. The patient also had a head CT whichshowed atrophy with old ischemic changes. No acute intracranialfindings.
CONSULTS OBTAINED: A rehab consult wasdone.
PAST MEDICAL/SURGICAL HISTORY: Positive foratrial fibrillation. The patient had AVR 6 years ago. Peripheralarterial disease with hypertension, peripheral neuropathy,atherosclerosis, hemorrhoids, proctitis, CABG, andcholecystectomy.
FAMILY HISTORY: Positive for atherosclerosis,hypertension, autoimmune diseases in the family.
SOCIAL HISTORY: Never smoked. Alcohol socially.No drugs.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
REVIEW OF SYSTEMS: Weight loss of 25 poundswithin the last 6 months, shortness of breath, constipation,bleeding from hemorrhoids, increased frequency of urination, muscleaches, dizziness and faintness, focal weakness and numbness in bothlegs, knees and feet.
PHYSICAL EXAMINATION: VITAL SIGNS: Bloodpressure 188/74, pulse 62, respirations 18 and saturation of 98% onroom air. General Appearance: The patient is a pleasant man,comfortable. HEENT: Conjunctivae are normal. PERRLA. EOMI. NECK: Nomasses. Trachea is central. No thyromegaly. LUNGS: Clear toauscultation and percussion bilaterally. HEART: Irregular rhythm.ABDOMEN: Soft, nontender, and nondistended. Bowel sounds arepositive. GENITOURINARY: Prostate is hypertrophic with smoothmargin. EXTREMITIES: Upper and lower limbs bilaterally normal.SKIN: Normal. NEUROLOGIC: Cranial nerves are grossly within normallimits. No nystagmus. DTRs are normal. Good sensation. The patientis alert, awake, and oriented x3. Mild confusion.
LABORATORY DATA AND RADIOLOGICAL RESULTS: WBC8.6, hemoglobin 13.4, hematocrit 39.8, platelets 207,000, MCV 91.6,neutrophil percentage of 72.6%. Sodium 133, potassium 4.7, chloride104. Blood urea nitrogen of 18 and creatinine of 1.1. PT 17.4, INR1.6, PTT 33.
The patient had a chest x-ray, which showed cardiomegaly withatherosclerotic heart disease, pleural thickening and small pleuraleffusion, a left costophrenic angle which has not changed whencompared to prior examination, COPD pattern. The patient also had ahead CT, which showed atrophy with old ischemic changes. No acuteintracranial findings.
HOSPITAL COURSE AND TREATMENT: This is an(XX)-year-old male with syncope.
1. Syncope. This may be secondary to questionable cerebralischemia/atrial fibrillation/hypotension, so Neurology was kept onboard and the patient was scheduled for a carotid Doppler and a 2-Decho. Orthostatics were ordered. Vitamin B12, TSH, free T4 and T3were ordered along with cortisol level in the morning. FOBT x3 weredone and cardiology followup as outpatient. The patient had acarotid Doppler done on the next day and it showed mild irregularplaque disease, right and left internal carotid arteries,approximately 20-59%. The patient’s vitamin B12 level came the nextmorning and the level was 1180. His folate was 18.7 and his TSH was1.98, free T4 of 1.38 and T4 level of 7.4, cortisol level of 15.4,which are within normal limits. Dr. Doe, who is the patient’scardiologist, was informed. Dr. Doe was kind enough to see thepatient the very next day, and his impression was that the patienthas atrial fibrillation, rate controlled, status post AVR, St.Jude, and peripheral neuropathy. Subtherapeutic INR, the patient’srelative target INR is 2-3. He suggested PT evaluation andsuggested a low dose of SSRI and Dr. Doe was of the opinion thatthe patient does not need any further cardiac recommendation. CTchest, abdomen, and pelvis were done. CT chest had an impression ofcoronary artery calcification, aortic valve replacement,cardiomegaly, suspect a very small left pleural effusion, no acuteactive pulmonary disease. CT abdomen and pelvis showed priorcholecystectomy, diverticulosis of sigmoid colon, twobenign-appearing simple cysts involving the right kidney, calcifiedarteriosclerotic plaque disease of the abdominal aorta and iliacvessels bilaterally. The patient was ruled out of any malignancywhatsoever.
2. Hypertension. The patient at home was on Cardizem ER 90 mgthrice daily, and it was changed initially to Cardizem 90 mg thricedaily, and then with Dr. Doe’s request, we changed the Cardizem to240 mg t.i.d.
3. Atrial fibrillation with subtherapeutic INR. The patient at homewas on Digitalis. That was continued. Dr. Doe was of the opinionthat the patient himself takes care of the Coumadin, and Dr. Doewas of the opinion that probably that is why the patient is notable to maintain therapeutic INR. In the hospital, the patient’swarfarin was increased to 5 mg q.h.s., and at the time of thedischarge, he was requested to follow his appointments so that hisINR can be maintained.
4. Gout. The patient was on allopurinol. There were no acute issuesregarding the gout.
5. Prophylaxis. The patient was on Protonix and TEDs.
6. Social. The patient is FULL CODE.
DISCHARGE DIAGNOSIS: Syncope.
DISCHARGE DISPOSITION: The patient isdischarged to home.
DISCHARGE MEDICATIONS: The patient wasdischarged on the following medications; Cardizem 90 mg p.o. thricedaily, digoxin 0.125 mg p.o. once daily, allopurinol 100 mg twotimes daily, Coumadin 4 mg p.o. q.h.s., and Remeron 15 mg p.o.q.h.s.
DISCHARGE INSTRUCTIONS: Since the patient hadgeneralized deconditioning, the patient was advised home PT, OT andthat was arranged for the patient.
DISCHARGE DIET: Cardiac diet.
DISCHARGE ACTIVITY: Resume activity astolerated.
List of all applicable diagnoses and assign a code each ofthem.
