Discharge Summary Medical Transcription Sample Report
ADMITTING DIAGNOSES:
1. Right-sided chest pain and shortness of breath, musculoskeletal versus postcardiotomy syndrome.
2. Diabetes.
3. History of hypothyroidism.
4. Hyperlipidemia.
5. History of redo coronary artery bypass grafting.
6. Prior history of obesity.
7. History of degenerative joint disease, status post previous spinal fusion.
8. History of dysfunctional uterine bleeding, status post dilatation and curettage.
DISCHARGE DIAGNOSES:
1. Right-sided chest pain and shortness of breath, musculoskeletal versus postcardiotomy syndrome.
2. Diabetes.
3. History of hypothyroidism.
4. Hyperlipidemia.
5. History of redo coronary artery bypass grafting.
6. Prior history of obesity.
7. History of degenerative joint disease, status post previous spinal fusion.
8. History of dysfunctional uterine bleeding, status post dilatation and curettage.
9. Uncontrolled blood glucose secondary to steroids.
HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: This pleasant (XX)-year-old patient, recently discharged after a CABG, presented to the hospital after the visiting nurse found her to have some chest pain and shortness of breath. She was brought to the ER. She was started on steroids. She was ruled out for another MI. A CT chest was done to rule out PE. She was ruled out for all that and did well on steroids. She had uncontrolled blood glucose secondary to steroids. Her medications were increased. Oral hypoglycemics were increased with improvement in her glucose control.
LABORATORIES AND CT: CT chest shows no evidence of pulmonary embolism, bibasilar infiltrate, bilateral effusions, aortopulmonary window adenopathy, atherosclerotic disease of the aorta. She had a white count of 12.5, hemoglobin of 10.4, and platelet count of 366,000. PT/INR was within normal range, and her BMP with sodium 133, potassium 5.2, chloride 94, CO2 of 26, glucose 303, BUN 26, creatinine 0.7, and calcium 9.2.
DISCHARGE DIRECTIONS: She was discharged to an extended care facility on tapering dose of steroids and her home medications. She would follow up with Cardiology in 1 to 2 weeks and follow up with Pulmonary in 1 to 2 weeks.
