Letter Data
Letter Type Discharge Summary
Dictating Date 01/01/01
Transcription Date 01/01/01

Admission Data
Admission Date 01/01/01
Admission Hospital Hospital Xxx

Patient Demographics
Patient Name X Xxx
Date of Birth 01/01/01
Age (in Text) XX-year-old

Physicians
Function Name
Dictating Dr. Dictating
Following Dr. Follow-up
Referring Dr. Referring, M.D.

Reason for admission
Reason for admission
atrial flutter rate controlled with variable block .

Present complaint anamnesis
Present complaint anamnesis
a two day history of generalized weakness and bilateral arm numbness when he assumes an upright posture .

Admission Medication
FreePharma
Components:
name strength strength unit strength base strength base unit
persantine 75 milligram n/a n/a
Route: per os
Dosages:
Dose 1
Quantity 1
Takes 3
Take Frequency day

Allergies
The patient is allergic to codeine which causes pruritus .

Main condition for treatment
Atrial flutter with controlled rate

Surgery performed during current hospitalization
Nature of surgery
ablation of his atrial flutter .

Previous surgery for same/related condition
Nature of surgery
coronary artery bypass graft x 2 vessels
PTCA with a stent placed in his RCA

Risk Factors
Risk Factor Current Risk Factor
Disease Risk Factors
Hypercholesterolemia Yes
Hypertension Yes
Coronary Artery Disease Yes
Other Risk Factors
Obesity Yes

Clinical examinations
Examination Result
Blood Pressure 138/84
Pulse 85
Respirations 20
Temperature afebrile

Tests and measurements
Heart investigations
Test Conducted Result
ECG at Rest Electrocardiogram on admission was atrial flutter with variable atrioventricular block .
ECG at Rest No acute ST or T wave changes were noted .
ECG at Rest Rate was 79 beats per minute .
Electrophysiology Study Electrophysiologic study with ablation of atrial flutter .

Lab results
Hematology
Labaratory test Result Normal Range
Hematocrit 39
Male 41 - 50%
Female 35 - 46%
Hemoglobin 13.1
Male 13.8 - 17.2 g/dL
Female 12.0 - 15.6 g/dL
Biochemistry
Labaratory test Result Normal Range
Elektrolytes
Sodium 134 135 - 146 mmol/L
Potassium 4.9 3.5 - 5.3 mmol/L
Chloride 104 95 - 108 mmol/L
Bicarbonate 17 21 - 28 mEq/L
Kidney Function
BUN (Blood Urea Nitrogen) 32 7 - 30 mg/dL
Creatinine 1.6 <=1.2 mg/dL
Heart Function
CK (Creatine Kinase) 52
Male <=235 U/L
Female <=190 U/L
CK-MB 4.4 < 3% of total
LDH (Lactate Dehydrogenase) 217 <=270 U/L

Discharge Medication
FreePharma
Components:
name strength strength unit strength base strength base unit
persantine 75 milligram n/a n/a
Route: per os
Dosages:
Dose 1
Quantity 1
Takes 3
Take Frequency day
FreePharma
Components:
name strength strength unit strength base strength base unit
norvasc 5 milligram n/a n/a
Route: per os
Dosages:
Dose 1
Quantity 1
Take Frequency every day

Discharge Information
Diagnosis Atrial flutter with controlled rate
Diagnosis Coronary artery disease .
Diagnosis Hypercholesterolemia .
Diagnosis Hypertension .
Condition He was considered stable to discharge home .
Activity As tolerated .
Diet 4 gm sodium cardiac prudent , low fat , low cholesterol diet .
Discharged to home
Discharge Date 01/01/01

Follow up
Reason Physician Date
control ecg Dr. Follow-up 01/01/01