Discharge Summary
Discharge Summary
Patient Information:
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Name: Carmel Ryan
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Age: 58
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Gender: Female
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Date of Admission: June 14, 2050
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Date of Discharge: June 20, 2050
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Medical Record Number: CR205062
Brief Hospital Course:
Carmel Ryan was admitted on June 14, 2050, with complaints of chest pain, shortness of breath, and diaphoresis. Initial evaluation revealed an ST-segment elevation myocardial infarction (STEMI) on the electrocardiogram (ECG). Prompt treatment was initiated with aspirin, clopidogrel, and intravenous heparin. An urgent coronary angiography revealed critical stenosis in the left anterior descending artery (LAD), necessitating a percutaneous coronary intervention (PCI) with stent placement. The procedure successfully restored blood flow to the affected area.
Hospital Course:
Throughout her hospital stay, Carmel Ryan remained hemodynamically stable. Cardiac enzyme levels trended downwards, indicating successful myocardial reperfusion. Continuous monitoring in the coronary care unit (CCU) showed no signs of arrhythmias or hemodynamic instability. Her chest pain resolved completely, and no further ischemic events were observed.
Diagnostic Tests:
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ECG: Showed ST-segment elevation in leads V1-V4, indicating an anterior wall myocardial infarction.
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Cardiac Enzymes: Elevated troponin levels peaked 12 hours post-PCI and subsequently decreased.
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Coronary Angiography: Revealed critical stenosis in the LAD, with successful PCI and stent placement.
Medications at Discharge:
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Aspirin 81 mg once daily
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Clopidogrel 75 mg once daily
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Atorvastatin 40 mg once daily
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Lisinopril 10 mg once daily
Follow-Up:
Dr. Sarah Patel is scheduled to follow up with a cardiologist in one week for a repeat ECG and further assessment of cardiac function. The patient is instructed to strictly adhere to the prescribed medication regimen, follow a heart-healthy diet, and engage in regular exercise as tolerated.
Discharge Instructions:
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Education: Carmel Ryan was educated on recognizing the signs and symptoms of a recurrent myocardial infarction and instructed to seek immediate medical care if they occur.
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Dietary Counseling: A low-sodium, low-fat diet was recommended to prevent future cardiovascular incidents.
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Smoking Cessation: Counseling was provided, and Carmel Ryan was referred to smoking cessation resources for support.
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Activity: Gradual resumption of activity is advised, starting with light exercises as tolerated.
Conclusion:
In summary, Carmel Ryan received prompt intervention with successful PCI, leading to stabilization of her cardiac condition. With proper discharge planning and follow-up care, continued recovery is anticipated. Strict adherence to the medication regimen, follow-up appointments, and lifestyle modifications are crucial to optimize long-term cardiovascular health.
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