Discharge summary preferred by Internal Medicine Attending Physicians at DRMC
MRN#
Service: internal medicine, attending Dr , resident Dr
Date of Admission:
Date of Discharge:
ADMITTING DIAGNOSES
- acute diverticulitis
- hypertension
- seizure disorder
- obesity
DISCHRAGE DIAGNOSE
- acute diverticulitis
2.hypertension
- seizure disorder
- obesity
- diabetes type 2
CONSULTS
Dr. Johnson
Dr. Abdollahzedeh
Dr. levinson
HISTORY OF PRESENT ILLNESS: (HPI on admission read off what HPI says)
This is a 43y/o male who presents to DRMC on 10/29/15 with the complaint of left sided abdominal pain with nausea. Patient stated that the pain started approximately x3 days ago. It has been constant and is rated at approximately 8/10 in intensity. Patient describes pain as sharp,stabbing, and mainly in the LLQ. The patient states the pain was unbearable. Therefore he went to the ED for further evaluation and treatment. Patient also had subjective fever and chills, however, denies night sweats. Patient had a similar attack several years ago and was diagnosed with diverticulitis….
IN THE EMERGENCY ROOM: (name all the radiology tests that were done)
Dr._____(whoever admitted the patient) EVALUATED THE PATIENT IN THE EMERGENCY ROOM AND ADMITTED THE PATIENT FOR: (admitting diagnoses). (then explain what treatments were given ) patient was started on Levaquin and flagyl IV antibiotics. Patient was kept NPO and IVF were given. Over a couple of days the patients pain subsided, he was given GI prophylaxis, DVT prophylaxis…
I EVALUATED THE PATIENT ON 10/31/15. At this time (write your latest overnight subjective note)
PHYSICAL EXAM:
VITALS:
LAB DATA: (lipase),(CBC,CMP)
DISPOSITION: AT THIS TIME , THE PATIENT IS STABLE FOR DISCHARGE HOME.
DISCHARGE MEDICATIONS: (list all PO d/c meds)
DISCHARGE INSTRUCTIONS: PATIENT UNDERSTANDS HE IS BEING DISCHARGED HOME IN STABLE CONDITION. Patient is to follow up with he primary care physician in 5-7 days. THE PATIENT UNDERSTANDS IF HE DEVELOPS (that if he has the same symptoms as before for the particular condition he has) TO CONSULT EMERGENCY ROOM FOR FURTHER EVALUATION AND TREATMENT.
Discharge summary dictated by Dr. ______ (resident) under the supervision of Dr _____ (attending).
The Dr attending saw and evaluated the patient with me.