Discharge summary admitting diagnosis


Assignment task:

Discharge Summary Admitting Diagnosis: Unstable angina History: This 69-year-old man was admitted through the ER with chest pain that began while he was eating his lunch. After lunch he went to do his grocery shopping and he began to develop discomfort in his chest and jaw. He drove himself to the ER. The ER physician admitted the patient due to unstable angina. Vital signs at the time of admission: BP: 140/60. Heart rate: 110 to 120. Hospital Course: Cardiac enzymes: CPK of 105, Troponin: 4.7 with a relative index of 5.4 Digoxin level of 1.8 All other lab values were normal. EKG was positive for a new anterior wall infarction. The patient was maintained on Imdur 30 mg daily and metoprolol 50 mg in the morning and evening. The patient stabilized and refused to stay in the hospital for additional workup. He was instructed to see me in 7 days or to call an ambulance if symptoms reoccur. Discharge Diagnoses: Acute anterolateral transmural Q wave infarction Hypertension

 

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Other Subject: Discharge summary admitting diagnosis
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