Discharge Summary:
Patient Information:
- Name: John Smith
- Date of Birth: 12/03/1978
- Medical Record Number: 1234567
Admission Details:
- Date of Admission: 28 October 2024
- Reason for Admission: Chest pain and shortness of breath.
Hospital Course:
- The patient presented to the emergency department with acute chest pain and shortness of breath. Initial assessment revealed elevated cardiac enzymes and ECG changes suggestive of a non-ST elevation myocardial infarction (NSTEMI). The patient was admitted to the cardiac unit. He underwent cardiac catheterisation, which revealed a 70% stenosis in the left anterior descending artery. A percutaneous coronary intervention (PCI) with stent placement was performed. The patient tolerated the procedure well and his chest pain resolved. He was monitored for 48 hours post-procedure without complications.
Discharge Diagnosis:
- Primary Diagnosis: Non-ST elevation myocardial infarction (NSTEMI)
- Secondary Diagnoses: Hypertension, Hyperlipidemia
Discharge Medications:
- Aspirin 81mg daily
- Clopidogrel 75mg daily
- Metoprolol 25mg twice daily
- Atorvastatin 40mg daily
Discharge Instructions:
- Activity: Gradual return to normal activity as tolerated. Avoid strenuous activity for 1 week.
- Diet: Follow a low-fat, low-cholesterol diet.
- Wound Care: Monitor the access site for any signs of infection (redness, swelling, drainage). Keep the site clean and dry.
- Follow-Up: Cardiology follow-up appointment in 2 weeks. Schedule with Dr. Jane Doe.
Additional Notes:
- Patient educated on the importance of medication adherence and lifestyle modifications.
Physician Information:
- Name: Dr. Thomas Kelly
- Contact Information: 020 7123 4567
Discharge Summary:
Patient Information:
- Name: [patient name] (only include patient name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Date of Birth: [patient date of birth] (only include patient date of birth if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Medical Record Number: [medical record number] (only include medical record number if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Admission Details:
- Date of Admission: [date of admission] (only include date of admission if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Reason for Admission: [reason for admission] (only include reason for admission if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Hospital Course:
- [summary of hospital course, including treatments, procedures, and progress] (only include summary of hospital course, including treatments, procedures, and progress if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Discharge Diagnosis:
- Primary Diagnosis: [primary diagnosis] (only include primary diagnosis if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Secondary Diagnoses: [secondary diagnoses] (only include secondary diagnoses if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Discharge Medications:
- [list of discharge medications, including dosages and instructions] (only include list of discharge medications, including dosages and instructions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Discharge Instructions:
- Activity: [activity instructions] (only include activity instructions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Diet: [diet instructions] (only include diet instructions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Wound Care: [wound care instructions] (only include wound care instructions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Follow-Up: [follow-up instructions, including appointments and referrals] (only include follow-up instructions, including appointments and referrals if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Additional Notes:
- [any additional notes or instructions] (only include any additional notes or instructions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Physician Information:
- Name: [physician name] (only include physician name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Contact Information: [physician contact information] (only include physician contact information if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture capture all the relevant information from the transcript.)
