Hospital Note
Hospital Note
Elena Shadow,
BlueHarbor Maritime Hospital
Date: August 15, 2050
Introduction
This document serves as a comprehensive record of the patient's treatment and care for in-patient stays at BlueHarbor Maritime Hospital. It focuses on transmitting accurate and precise healthcare information for the purpose of continuity of care, treatment plan, patient safety and quality healthcare service.
Patient Information
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Patient Name: John Doe
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Age: 45
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Sex: Male
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Admission Date: August 10, 2050
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Discharge Date: August 15, 2050
Medical History
Mr. Doe has a history of hypertension and type II diabetes. He has been on medication for the past five years.
Presenting Complaint
Presentation of severe chest pain, shortness of breath and palpitations on August 10, 2050.
Investigations and Results
Detailed examinations and tests were conducted which include ECG, blood tests, and an MRI scan. Findings were suggestive of acute myocardial infarction (heart attack).
Treatment Plan
The patient was immediately started on anticoagulants and pain management therapy. A referral for an angioplasty was made and successfully carried out on August 11, 2050.
Progress Notes
Patient's condition improved significantly post-surgery with reduction in chest pain and normalization of heart rate and blood pressure levels. Physical therapy was introduced on August 12, 2050 and a controlled diet plan was followed for managing the patient's diabetes and hypertension.
Discharge Instructions
Patient was discharged on August 15, 2050 in stable condition. Instructions have been provided to continue medication for hypertension and diabetes as previously. A cardiac rehabilitation programme and lifestyle modifications have also been recommended. Discharge instructions also include regular monitoring of blood pressure, blood sugar levels and reporting of any chest discomfort.
Follow Up and Next Steps
The patient is scheduled for a follow up visit on August 30, 2050 to assess the progress after discharge. The continuation of lifestyle modifications and medication adherence will be discussed during the follow up visit.
Elena Shadow,
BlueHarbor Maritime Hospital
