Download Discharge Summary Template - 33.5 KB

PATIENT NAME:
ADMIT DATE:
DISCHARGE DATE:
ATTENDING MD:
XXXXXX
12/13/2008
12/18/2008
XXXXXX
PRINCIPAL DIAGNOSES:
1.
Hematuria.
2.
Urinary tract infection.
3.
Congestive heart failure.
4.
Atrial fibrillation.
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old female with multiple
medical problems who was admitted to Wesley Woods Hospital from home, via the
ED, with gross hematuria for 3 days. The ER reported prior to admission, the
patient had gross hematuria and has had a CAT scan then that showed that she
had clots in her bladder and there was diverticula. It was felt at the time
of admission was that the patient may have a urinary tract infection and was
transferred to Wesley Woods for further management.
PAST MEDICAL HISTORY:
1.
Hypertension.
2.
Atrial fibrillation, not on Coumadin.
3.
DJD.
4.
Anxiety.
5.
Urge incontinence.
6.
History of GI bleed.
7.
Fibrocystic breast disease.
MEDICATIONS PRIOR TO ADMISSION :
1.
Metoprolol 25 mg every 12 hours.
2.
Lisinopril 5 mg daily.
3.
Aspirin 81 mg daily.
4.
Lasix 20 mg daily.
5.
Potassium chloride 10 mEq daily.
6.
Vitamin D 400 units daily.
7.
Aricept 5 mg at bedtime.
8.
Effexor 75 mg at bedtime.
9.
Klonopin 0.5 mg at bedtime.
REVIEW OF SYSTEMS: The patient noted to be tired and denied having any fever
or chills. She did have history of easy bruisability. History of decreased
cognition.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 155/84, respiratory rate is 16, pulse ox 98
percent on room air, and her pulse was 100.
GENERAL: The patient was drowsy but arousable on admission.
CARDIOVASCULAR: S1, S2 present. It was irregular rhythm murmur.
RESPIRATORY: Chest was clear to auscultation bilaterally.
GASTROINTESTINAL: The abdomen was soft, nontender. Bowel sounds present.
GENITOURINARY: The patient had a Foley catheter in
place and she has gross hematuria. Initially, did not have any clots in the
catheter.
SKIN: She has ecchymoses at multiple sites.
HEMATOLOGIC: Easy bruisability.
LABS AND DIAGNOSTIC STUDIES ON ADMISSION: The patient had an initial
hematocrit of 37.5. Platelets were 318 and coagulation parameters were within
normal limits. Her electrolytes and renal function were within normal limits.
HOSPITAL COURSE:
1. Hematuria. Initially, the patient had her Foley catheter irrigated every
shift; however, there was concern there would be clot in and so she was
started on continuous bladder irrigation. She was later noted to have clots
around her Foley catheter, and she was also noted to have a significant drop
in her hematocrit. The patient also was noted to be complaining of abdominal
discomfort. The patient’s hematuria resolved after three days of bladder
irrigation, and the foley was discontinued on the day before discharge.
2. Urinary tract infection. The patient's urine culture was
positive for greater than 100,000 gram-negative rods, and she was placed
empirically on levofloxacin.
3. Congestive heart failure. The patient is known to have an ejection
fraction of 50 to 65 percent and had some shortness of breath on presentation
and a BNP which was elevated up to 1,000. She was given an extra 20 mg of
Lasix in addition to her 20 mg p.o. Lasix, up to a dose of 20 mg bid. The
shortness of breath improved, and the BNP decreased to 450.
4. Hypertension. Blood pressure remains stable. There were no medication
changes made during the hospitalization.
5. History of atrial fibrillation. The patient's aspirin was held given her
bleeding. After the hematuria resolved, aspirin was resumed before
discharge.
Code Status: The patient was placed as DNR as per her family.
Discharge Medications:
1.
Metoprolol 25 mg every 12 hours.
2.
Lisinopril 5 mg daily.
3.
Aspirin 81 mg daily.
4.
Lasix 20 mg bid (changed from 20 mg qday)
5.
Potassium chloride 10 mEq daily.
6.
Vitamin D 400 units daily.
7.
Aricept 5 mg at bedtime.
8.
Effexor 75 mg at bedtime.
Discharge Plan: Ms. XXXX will return home, where she will receive round-theclock assistance from her daughter Elizabeth. We have set up home healthcare
services for her, including nursing to monitor hematuria, as well as PT/OT.
She has a follow-up appointment in two weeks with Dr. Richards, her PCP, whom
we have contacted to update on her care.
Please be sure to document the following in your discharge summaries:
1.
2.
3.
4.
5.
Admission medication list with doses.
Physical exam and lab/diagnostic tests.
An itemized hospital course by problem or organ system.
Detailed discharge medications, including medication changes.
Detailed discharge plan, including location and planned follow-up.