ADT Information
Patient Name             		Mr. X Xxx
Patient DOB              		01/01/01
Admission Date         		        01/01/01
Discharge Date        		        01/01/01

Dictated Information
Hospital                		Hospital Xxx
Date of Dictation        		01/01/01
Dictator / Resident      		Dr. Dictating
Report Type              		Discharge Summary
Date of Transcription   		01/01/01

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DISCHARGE DIAGNOSES:		1.  Atrial flutter with controlled rate.
                        	2.  Coronary artery disease.

SECONDARY DIAGNOSES:		1.  Hypercholesterolemia.
                         	2.  Hypertension.

PROCEDURES: 	Electrophysiologic study with ablation of atrial flutter.

DISCHARGE MEDICATIONS:  Persantine 75 mg 1 p.o. t.i.d., Norvasc 5 mg 1 p.o. q.d.

HISTORY AND PHYSICAL:  Mr. Xxx is a XX-year-old white male with multiple medical 
problems with a long cardiac history who presents with a two day history of generalized 
weakness and bilateral arm numbness when he assumes an upright posture. Cardiac history 
begins in 1985 when the patient had a myocardial infarction. The patient had a coronary 
artery bypass graft x 2 vessels and a PTCA with a stent placed in his RCA.

PAST MEDICAL HISTORY: 	1) Coronary artery disease as above. 2) Peptic ulcer disease.  
3) Hypercholesterolemia.  4) Hypertension.  

MEDICATIONS ON ADMISSION:   Persantine 75 mg 1 p.o. t.i.d.

ALLERGIES:  The patient is allergic to codeine which causes pruritus.

PHYSICAL EXAMINATION:  The patient is an obese, white male in no apparent distress.  
Pulse 85, respirations 20, blood pressure 138/84.  Temperature is afebrile.  
HEENT:  Pupils are equal, round and reactive to light.  NECK:  Supple without 
lymphadenopathy. CARDIOVASCULAR:  Heart sounds are irregularly irregular without 
murmurs, rubs or gallops. PULMONARY:  Clear.  ABDOMEN:  Soft,nontender with good 
bowel sounds.

Electrocardiogram on admission was atrial flutter with variable atrioventricular block.  
No acute ST or T wave changes were noted. Rate was 79 beats per minute.   
Labs on admission:  Sodium 134, potassium 4.9, chloride 104, bicarbonate 17, BUN 32, 
creatinine 1.6. LDH 217,  total CK 52 with a MB fraction of 4.4.  The H&H was 13.1 
and 39.

HOSPITAL COURSE:  
I.  ATRIAL FLUTTER.  The patient was admitted with atrial flutter rate controlled with 
variable block. On the day after admission, the patient went for electrophysiologic 
study and underwent ablation of his atrial flutter. On discharge, the patient was in 
sinus rhythm at a rate of 67 with occasional first degree AV block and PVCs.  He was 
considered stable to discharge home.

II.  HYPERTENSION.  The patient's blood pressure was within normal limits during his 
hospital stay. 

DISCHARGE FOLLOW-UP:  The patient is to follow up with Dr. Follow-up on 01/01/01 
for control ECG.

DISCHARGE DIET:  4 gm sodium cardiac prudent, low fat, low cholesterol diet.

DISCHARGE ACTIVITY:  As tolerated.
_______________________
Dr. Dictating

DD:  01/01/01   DT:  01/01/01

REFERRING:  Dr. Referring, M.D.