Generic NHS Discharge Summary

St. Mary's Hospital St. Mary's NHS Trust Tel: 020 7946 0958 Dr. Thomas Kelly Cardiology Department 123 Health Street, London, W1A 1AA DISCHARGE SUMMARY Date: 01/11/2024 10:00 Discharge Status: Final Discharge Summary Name: John Smith MRN: 123456789 Gender: Male D.O.B.: 15/05/1970 NHS Number: 9876543210 Home Telephone: 020 7946 1234 Mobile Telephone: 07700 900123 Address: 45 Elm Road, London, W2 3RT Admission Date/Time: 28/10/2024 14:30 Discharge Date/Time: 01/11/2024 09:00 Consultant: Dr. Thomas Kelly Outcome: Discharged with consent Presenting Complaint: Patient presented with chest pain and shortness of breath. Discharging Ward: Cardiology Ward Discharging Hospital: St. Mary's Hospital Discharged by: Nurse Sarah Johnson Discharge Method: Usual place of residence CLINICAL SUMMARY Admission Information Admission Diagnosis: Acute Myocardial Infarction (I21.9) Problems Co-morbidities: Hypertension, Type 2 Diabetes All Problems - Acute Myocardial Infarction - Hypertension - Type 2 Diabetes Allergies Allergies: Penicillin Allergic Reactions (Selected): Rash and swelling (severe) Medications Warfarin treatment: Not required Medications to take home: - Aspirin 75 mg, once daily, indefinitely - Metformin 500 mg, twice daily, ongoing - Lisinopril 10 mg, once daily, ongoing Discharge Plan Advice, Recommendations and Future Plan GP: Follow-up appointment in 2 weeks to monitor blood pressure and glucose levels. Community/Specialist Services: Referral to cardiac rehabilitation program. Other Details: Patient advised to avoid strenuous activities for 4 weeks and to follow a heart-healthy diet. Signed by: Nurse Sarah Johnson Bleep/Tel: 020 7946 5678 Grade: Nurse