Clinical note · #54
Hospital & observation
Patient Name: George Thompson
MRN: 87654312
Date of Admission: 09/14/2024
Date of Discharge: 09/21/2024
Attending Physician: Dr. John Peterson
Primary Diagnosis: Acute decompensated heart failure
Secondary Diagnosis: Hypertension, Hyperlipidemia
Hospital Course:
George Thompson, a 70-year-old male with a history of chronic heart failure, was admitted for worsening dyspnea and edema. He was treated with intravenous diuretics, resulting in symptom improvement. Time was spent educating the patient and family on medication adherence, fluid restriction, and weight monitoring.
Final Physical Exam:
- Vitals: BP 130/82, HR 70, O2 Sat 97% on room air
- Heart: Regular rate, S3 present
- Lungs: Clear
- Extremities: 1+ edema bilaterally
Discharge Medications:
- Furosemide 40 mg daily
- Spironolactone 25 mg daily
- Metoprolol 50 mg twice daily
Discharge Instructions:
- Limit daily fluid intake to 1.5 liters
- Low-sodium diet (less than 2g/day)
- Daily weight monitoring; report weight gain of more than 3 pounds in 24 hours
- Take medications as prescribed
Follow-Up:
- Follow-up with cardiology in 5 days
- Home health services arranged
Discharge Condition:
Stable with mild residual edema.
Discharge Time: 45 minutes
Disposition: Discharged home with family support.