DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMITTING DIAGNOSIS: Hematuria.
DISCHARGE DIAGNOSES:
1. Hematuria, resolved.
2. Atrial flutter and atrial fibrillation, ablation on MM/DD/YYYY.
3. History of myocardial infarction, anterior coronary stenting on MM/DD/YYYY.
4. History of dyspnea.
5. Ischemic heart disease, left ventricular ejection fraction of 25%.
6. Possible passage of renal calculi.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old gentleman who was just discharged from the hospital the day before admission here after undergoing an ablation for his atrial fibrillation and atrial flutter. He was discharged on outpatient Lovenox and Coumadin in stable condition. He states that he has noticed a red color to his urine and also had some shortness of breath, and he was admitted for further evaluation.
HOSPITAL COURSE: The patient was admitted and placed on routine cardiac telemetry orders, and urology was consulted and Dr. John Doe saw him in this regard. He also underwent a V/Q scan, which was low probability for pulmonary embolism. He had a chest x-ray that was unremarkable other than a small left pleural effusion and Lasix was begun.
He stated that he had some right inguinal site discomfort, and he passed some blood in urine and then the discomfort was relieved and afterwards that hematuria also cleared out. He subsequently had clear urine from that point on. He had an IVP and showed possible prostatic enlargement and no real opaque calculi formation or obstructive uropathy.
He did well with increased activity, and he was discharged home in stable condition.
DISCHARGE INSTRUCTIONS: The patient is to follow with Dr. Jane Doe in one to two weeks. He is to follow a heart-healthy diet with light and easy gradual return to normal activity over the next day or two. He is to obtain PT, INR, and to avoid all smoking or tobacco product exposure.
MEDICATIONS ON DISCHARGE: Coumadin 5 mg on Monday, Wednesday, and Friday, 7.5 mg on Tuesday, Thursday, Saturday, and Sunday; Zocor 10 mg at bedtime; Pepcid 20 mg daily; Cordarone 200 mg daily; Coreg 3.125 mg b.i.d. ; Lasix 20 mg daily; and K-Dur 20 mEq daily.
CONDITION: The patient was discharged stable.
