Shortness of Breath Discharge Summary Sample
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DIAGNOSES:
1. Shortness of breath.
2. Aortic valve disorder.
3. Hypertension.
4. Malignancy of the prostate.
5. Diabetes.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old male patient who is well known to us, diagnosed with a prostate carcinoma. He also has history of diabetes, no past history of coronary artery disease, presented to the emergency department with shortness of breath and lower extremity edema. He is denying chest pain. He was treated in the ER and then admitted for further evaluation and treatment.
HOSPITAL COURSE: Upon admission, the patient was placed on IV fluids. Labs were obtained. Chest x-ray was ordered. Consult was made to the cardiologist, and the patient was ordered to a monitored bed. The patient was seen in a consultation by Dr. John Doe. After his assessment, impression was dyspnea, metastatic prostate cancer, hypertension, and diabetes. The plan was to rule out myocardial infarction with serial cardiac enzymes and ECG. Continue medical therapy and aspirin daily. Check echocardiogram. Start the patient on Zestril. Give Lasix for edema. Check basic metabolic panel. Check CT scan of the chest to evaluate for metastatic disease or pulmonary embolism. Medical management from cardiac standpoint.
CT of the chest revealed no evidence of major central pulmonary emboli, interstitial pattern, particularly prominent at the bases, which could be chronic with a mild hazy pattern at both bases. Could be active interstitial process superimposed upon chronic interstitial lung disease. No consolidation, no pneumothorax, no pleural effusion. Vascular calcification of the aorta and branching vessels, particularly of coronary arteries, multiple. Cardiac enzymes were normal. A bone scan obtained revealed multiple metastatic lesions as described, both kidneys functioning, no hydronephrosis noted. The patient responded well to medical management.
Case management was consulted with regard to discharge planning. The patient, at this time, is living with his ex-girlfriend. Placement was requested. Once arrangements were made, the patient was then discharged to the extended care facility.
