Discharge Summary: The Cardiorespiratory System

Translate into medical terms or abbreviations common terms contained in a patient's discharge summary. Identify 5 drugs appearing in the discharge summary and specify the usage reason for each drug on the provided template. 

Instructions

Review the patient's discharge summary below. Next, download the Discharge Summary Template [DOCX] and complete all of the following:

· Identify 10 common terms contained in the discharge summary and correctly translate them into medical terms or abbreviations. Remember, you must spell the common and medical terms or abbreviations correctly.

· Identify 5 drugs that appear in the discharge summary and specify the reason each drug is used.

· Cite in correct APA style the references you used to perform your translation. 

 Discharge Summary: Cardiorespiratory

Discharge Diagnosis

1. Non-ST-elevation myocardial infarction.

2. Moderate coronary artery disease.

3. Stroke.

4. High blood pressure.

5. An abnormally high concentration of lipids in the blood.

6. Chronic obstructive pulmonary disease.

7. Chronic systolic congestive heart failure.

Procedures

Left heart catheterization, medical imaging test to determine cardiac function in the left ventricle, medical imaging used to visualize coronary arteries with stent placement, computed tomography scan, magnetic resonance imaging scan, posterior artery in the brain repair with stent placement.

Brief History

This 72-year-old male presented to the emergency room with chest pain, shortness of breath, and left arm numbness. Patient has a history of high blood pressure, an abnormally high concentration of lipids in the blood, chronic obstructive pulmonary disease, and congestive heart failure. In the emergency room, troponin levels and EKG results came back positive for Non-ST-elevation myocardial infarction. Patient was taken directly to the cardiac catheterization lab.

Past Medical History

High blood pressure, an abnormally high concentration of lipids in the blood, chronic obstructive pulmonary disease, and congestive heart failure, asthma as a child, previous right total knee replacement.

Medications

Norvasc, Lipitor, Lasix, Cozaar, oxygen dependent.

Family History

Patient is adopted and does not know family history; all children are healthy.

Social History

Former smoker, no alcohol or illegal drugs.

Allergies

Penicillin, Sulfa.

Physical Exam

GENERAL: Alert and oriented X3.

HEENT: Normocephalic and atraumatic, blindness over half the field of vision.

LUNGS: Few rales in lower lobes.

HEART: RRR without murmur.

ABDOMEN: Soft, non-tender, without swelling or masses.

EXTREMITIES: 2+ edema in lower extremities, no cyanosis.

Hospital Course

This is a 72-year-old male who was taken directly to the cardiac catheterization lab from the emergency department due to an evolving Non-ST-elevation myocardial infarction. A 98% close to the center right coronary artery lesion was treated with a Cypher 3.5 x 13 mm stent. The left descending artery showed 35% stenosis, and the left circumflex artery showed 25% stenosis. The image of the left ventricle demonstrated an ejection fraction of 40%. Following the procedure, the patient was admitted to the telemetry unit for observation. He remained in stable condition without chest pain but developed an irregular, rapid heartbeat. The next day, the patient complained of a severe headache in the back of his head with double vision and only being able to see from half of his eye. The patient was taken for a computed tomography scan and magnetic resonance imaging scan which showed a blood clot blocking the posterior artery in the brain. The patient was take back to the catheterization room where a catheterization of the head artery was performed to remove the blood clot and to place a stent to keep the vessel open. Patient is being discharged home on routine meds to follow up with primary care physician within 7 days.

Discharge Summary Template

References in APA Format 

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