DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease.
2. Congestive heart failure, compensated.
3. Peripheral vascular disease.
4. Pulmonary hypertension.
5. Left carotid stenosis.
DISCHARGE MEDICATIONS: Albuterol nebulizer 4 times per day, potassium 40 mEq p.o. daily, Plavix 75 mg daily, Coreg 6.25 mg b.i.d., Ecotrin 325 mg daily, calcium with vitamin D p.o. daily, multivitamin p.o. daily, torsemide 20 mg p.o. daily, Pravachol 40 mg p.o. daily, Zetia 10 mg p.o. daily, diltiazem ER 180 mg p.o. daily, Digitek 0.125 mg p.o. daily, Singulair 10 mg p.o. daily, Advair 250/50 one puff b.i.d., Revatio 20 mg t.i.d., prednisone with the titrating weaning dose, Avelox 400 mg daily, and Mucinex 2 tablets b.i.d.
FOLLOWUP: The patient is to follow up with Dr. John Doe in 2 weeks, to follow up with primary care physician in 7 days, and to follow up with Dr. Jane Doe next week.
CONSULTANTS: The patient was seen in consultation by Vascular Surgery and Cardiology.
HOSPITAL COURSE: The patient is a (XX)-year-old Hispanic female with a past medical history of atrial fibrillation, COPD, primary hypertension, history of aortic valve replacement, history of coronary artery bypass grafting, peripheral vascular disease, and history of chronic renal insufficiency who had presented to the emergency room with a chief complaint of severe shortness of breath associated with bilateral lower extremity swelling.
After the patient was evaluated by the emergency room physician and receiving nitroglycerin and intravenous Bumex as well as Rocephin and nebulizer treatment, the patient is being admitted for further evaluation and care. The patient was admitted to the progressive care unit. Pulmonary consultation was made. Cardiology was also asked to see the patient in consultation.
The patient was started on IV Solu-Medrol as well as Lasix and Avelox. The patient was ruled out for acute myocardial infarction. Carotid Doppler studies were obtained revealing the patient to have at least moderate disease involving the common carotid artery and severe disease involving the left internal carotid artery and left external carotid artery.
Vascular Surgery was asked to see the patient in consultation who elected medical management for the patient’s carotid artery disease. The patient was felt to be safe for discharge. Her breathing had markedly improved, and all consultants were in agreement with the patient’s discharge plan. The discharge plan was discussed with the patient who was in agreement with it as well, and her questions were answered to her fullest satisfaction.
