Discharge Summary Template

Link to Recording:

References

Bulsara, K. G., & Cassagnol, M. (2023). Amlodipine. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK519508/

Khan, T. M., Patel, R., & Siddiqui, A. H. (2023). Furosemide. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499921/

McIver, L. A., & Siddique, M. S. (2024). Atorvastatin. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430779/

Mulla, S., & Siddiqui, W. J. (2022, July 18). Losartan. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526065/

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Change common terms contained in a patient’s discharge summary into medical terms or abbreviations. Identify five drugs appearing in the discharge summary and specify the usage reason for each drug on the provided template. Record yourself reading the patient’s discharge summary (1–2 single spaced pages).

Introduction
In this assessment, you will focus your attention on the blood, heart, and lungs. The heart and blood forms the circulatory system. The blood picks up oxygen from the lungs and carries the oxygen to the cells in the body. The heart pumps the blood moving through the body.

The respiratory system is the lungs and passageways that bring in oxygen. You will have a chance to show your knowledge of the purpose, parts, and functioning of these systems. In addition, you will show your knowledge of diseases, diagnostic studies, and treatments, including drugs.

In the assessment you will review a discharge summary. This is for a patient with cardiorespiratory disease. Show your command of medical terms, including your pronunciation of the terms through an audio recording.

Preparation
You will record yourself pronouncing terminology in this assessment. If you have not yet set up a microphone and practiced recording, refer to Audio and Video in this Course in the Tools and Resources menu for information. Before you begin the assessment, set up your microphone or headset and practice using your equipment to ensure you are able to record and that your audio quality is adequate.

Note: If you require the use of assistive technology or alternative communication methods to participate in this activity, please contact [email protected] to request accommodations.

Instructions
Review the patient’s discharge summary below. Next, download the Discharge Summary Template [DOCX] and complete all of the following:

Part 1

• Identify eight common terms contained in the discharge summary.
• Correctly change them into medical terms or abbreviations.
• Identify two common terms related to specialized areas for medicine (radiology, surgery, or procedures) in the discharge summary.
• Correctly change them into medical terms or abbreviations.
• Identify five drugs that appear in the discharge summary.
• Specify the reason each drug is used.

Part 2

• Record yourself reading the discharge summary with the correct medical terms.
• In your recording, you need to correctly pronounce all the medical terms.
• In addition, be sure to use appropriate tone, volume, and clarity for professional communication in the health care field.
• Include the link to your recording in the Discharge Summary Template when you submit it.

Discharge Summary: Cardiorespiratory
Discharge Diagnosis

• Non-ST-elevation myocardial infarction.
• Moderate coronary artery disease.
• Stroke.
• High blood pressure.
• An abnormally high concentration of lipids in the blood.
• Chronic obstructive pulmonary disease.
• Chronic systolic congestive heart failure.

Procedures
Left heart catheterization, medical imaging test to determine cardiac function in the left ventricle, medical imaging used to visualize coronary arteries with stent placement, computed tomography scan, magnetic resonance imaging scan, posterior artery in the brain repair with stent placement.

Brief History
This 72-year-old male presented to the emergency room with chest pain, shortness of breath, and left arm numbness. Patient has a history of high blood pressure, an abnormally high concentration of lipids in the blood, chronic obstructive pulmonary disease, and congestive heart failure. In the emergency room, troponin levels and EKG results came back positive for Non-ST-elevation myocardial infarction. Patient was taken directly to the cardiac catheterization lab.

Past Medical History
High blood pressure, an abnormally high concentration of lipids in the blood, chronic obstructive pulmonary disease, and congestive heart failure, asthma as a child, previous right total knee replacement.

Medications
Norvasc, Lipitor, Lasix, Cozaar, oxygen dependent.

Family History
Patient is adopted and does not know family history; all children are healthy.

Social History
Former smoker, no alcohol or illegal drugs.

Allergies
Penicillin, Sulfa.

Physical Exam
GENERAL: Alert and oriented X3.

HEENT: Normocephalic and atraumatic, blindness over half the field of vision.

LUNGS: Few rales in lower lobes.

HEART: RRR without murmur.

ABDOMEN: Soft, non-tender, without swelling or masses.

EXTREMITIES: 2+ edema in lower extremities, no cyanosis.

Hospital Course
This is a 72-year-old male who was taken directly to the cardiac catheterization lab from the emergency department due to an evolving Non-ST-elevation myocardial infarction. A 98% close to the center right coronary artery lesion was treated with a Cypher 3.5 x 13 mm stent. The left descending artery showed 35% stenosis, and the left circumflex artery showed 25% stenosis. The image of the left ventricle demonstrated an ejection fraction of 40%.

Following the procedure, the patient was admitted to the telemetry unit for observation. He remained in stable condition without chest pain but developed an irregular, rapid heartbeat. The next day, the patient complained of a severe headache in the back of his head with double vision and only being able to see from half of his eye. The patient was taken for a computed tomography scan and magnetic resonance imaging scan, which showed a blood clot blocking the posterior artery in the brain.

The patient was taken back to the catheterization room where a catheterization of the head artery was performed to remove the blood clot and to place a stent to keep the vessel open. The patient is being discharged home on routine meds to follow up with a primary care physician within 7 days.

Additional Requirements

• What to Submit: Submit the Discharge Summary Template with a link to your recording in the document.
• Format: Use the Discharge Summary Template.
• Scoring Guide: Be sure to read this assessment’s scoring guide, so you understand how your faculty member will evaluate your Discharge Summary Template.
  

  Discharge Summary Template

Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

• Competency 1: Use medical terminology and abbreviations related to pharmacology.
  • Identify drugs correctly.
  • Specify the correct reason for the drug’s use.
• Competency 2: Use medical terminology and abbreviations related to general structures and functions of the human body.
  • Identify common terms related to general structures and functions of the human body correctly.
  • Change common terms related to general structures and functions of the human body into medical terms or abbreviations correctly.
• Competency 3: Use medical terminology and abbreviations related to body systems.
  • Identify common terms related to body systems correctly.
  • Change common terms related to body systems into medical terms or abbreviations correctly.
• Competency 4: Use medical terminology and abbreviations related to specialized areas of medicine.
  • Identify common terms related to specialized areas of medicine correctly.
  • Change common terms related to specialized areas of medicine into medical terms or abbreviations correctly.
• Competency 6: Spell and pronounce basic medical terms.
  • Spell common and medical terms or abbreviations correctly.
  • Pronounce medical terms correctly.
• Competency 7: Communicate in a professional manner.
  • Use tone and clarity reflective of professional communication in a health care setting.