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Discharge Summary Example
Care Transitions – Intern Orientation
Patient Identifier
Name: Josephine Smith
MRN: 1234567
Date of admission: 5/7/2011
Date of discharge: 5/14/2011
Primary care provider: Dr. Bill Scott, at 404-555-4000
Attending of Record: Dr. Y. Taylor
Primary Diagnosis: Acute on chronic systolic congestive heart failure exacerbation, EF 15%
Secondary Diagnoses:
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Atrial Fibrillation with rapid ventricular response, rate controlled.
Moderate to severe tricuspid regurgitation
E.coli urinary tract infection, treated this admission
Mild dementia with superimposed delirium during this admission, returned to baseline mental
status at the time of discharge
Gout flare during this admission requiring prednisone taper.
Chronic kidney disease, stage III, baseline Cr 2.0, Type 2 diabetes. Last A1C on 3/20/11 - 7.0
Hypertension
Bladder cancer – S/P XRT 2005
Hospital course by problem list:
Brief HPI: Ms Smith is an 82-year-old woman admitted a three day history of shortness of breath, cough,
and orthopnea with associated bilateral leg swelling. Pertinent findings on exam included hypoxia with
oxygen saturation of 82%, irregularly irregular heart rhythm with a rate of 120, slight volume overload
with 1+ pitting edema and bibasilar crackles. Her blood pressure was 150/95.
1. Congestive Heart Failure Exacerbation: Initially volume overloaded with BNP of 2190. Serial
cardiac enzymes were negative. Chest X-ray revealed pulmonary edema. A 2D echo revealed
severe systolic dysfunction with an ejection fraction of 15 percent. She diuresed well on
furosemide 100mg IV and chlorothiazide 500 mg iv daily and afterload reduction with addition
of hydralazine/isosorbide dinitrate. Her creatinine was transiently elevated to 2.5 with diuresis
but was at baseline of 2.0 at discharge. BNP was repeated and went down from 2190 to 1174. At
discharge, she was euvolemic on oral diuretics at her dry weight of 160lb.
2. Atrial Fibrillation with rapid ventricular response: She presented with heart rate of 120, and
was rate controlled on metoprolol. Her family declined warfarin therapy. She was continued on
aspirin.
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3. Mild Dementia with superimposed delirium secondary to E. Coli UTI: Ms. Smith became quite
confused with fluctuating mental status during the course of her hospitalization and was found
to have UTI which was treated with levaquin.
Disposition at discharge: She is euvolemic. Cognitively, she is alert and oriented x 3. Functionally, she
walks about 50 feet with no help, though she does get short of breath with longer distances. She lives
alone so home health services were arranged. Daughter (Renee Smith 404.722.3344) will check in on
her daily. She is full code.
Discharge instructions: Patient was counseled on daily weights, 2gm sodium diet, and diuretic dosing.
Follow-up appointment: PCP Dr. Bill Scott, on 6/21/2011 at 9.00am.
Discharge medications:
New medications started during this admission:
1. Hydralazine/Isosorbide Dinitrate (37.5/20) 1 tab po q 8 hrs
2. Prednisone 30mg po qday for 3days, then 20mg po qday for 3days, then 10mg po qday x2days
3. Metoprolol 50 mg po bid
4. Colchicine 0.6 mg po qday
Previously prescribed medications with a new dose
1. Aspirin 81mg by mouth daily
Previously prescribed medications to be continued upon discharge:
1. Furosemide 40 mg once a day
2. Calcium with Vitamin D, one tab daily
3. Allopurinol 100 mg po daily
4. Escitalopram 10 mg po daily
5. Donepezil 10 mg po daily
6. Glipizide 5 mg po bid
7. Lisinopril 10 mg po qday
Medications to be stopped:
None
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