Sample Name: ESRD - Discharge Summary
Description: This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis and is also status post cadaveric kidney transplant with chronic rejection.
(Medical Transcription Sample Report)
ADMISSION DIAGNOSIS: End-stage renal disease (ESRD).
DISCHARGE DIAGNOSIS: End-stage renal disease (ESRD).
PROCEDURE: Cadaveric renal transplant.
HISTORY OF PRESENT ILLNESS: This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis since 1993 and is also status post cadaveric kidney transplant in 1996 with chronic rejection.
PAST MEDICAL HISTORY:
1. Diabetes mellitus diagnosed 12 years ago.
3. Coronary artery disease with a myocardial infarct in September of 2006.
4. End-stage renal disease.
PAST SURGICAL HISTORY: Coronary artery bypass graft x5 in 1995 and cadaveric renal transplant in 1996.
SOCIAL HISTORY: The patient denies tobacco or ethanol use.
FAMILY HISTORY: Hypertension.
GENERAL: The patient was alert and oriented x3 in no acute distress, healthy-appearing male.
VITAL SIGNS: Temperature 96.6, blood pressure 166/106, heart rate 83, respiratory rate 18, and saturations 96% on room air.
CARDIOVASCULAR: Regular rate and rhythm.
PULMONARY: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, and nondistended with positive bowel sounds.
EXTREMITIES: No clubbing, cyanosis, or edema.
PERTINENT LABORATORY DATA: White blood cell count 6.4, hematocrit 34.6, and platelet count 182. Sodium 137, potassium 5.4, BUN 41, creatinine 7.9, and glucose 295. Total protein 6.5, albumin 3.4, AST 51, ALT 51, alk phos 175, and total bilirubin 0.5.
DISCHARGE INSTRUCTIONS: The patient is discharged with instructions to seek medical attention in the event if he develops fevers, chills, nausea, vomiting, decreased urine output, or other concerns. He is discharged on a low-potassium diet with activity as tolerated. He is instructed that he may shower; however, he is to undergo no underwater soaking activities for approximately two weeks. The patient will be followed up in the Transplant Clinic at ABCD tomorrow, at which time, his labs will be rechecked. The patient's Prograf levels at the time of discharge are pending; however, given that his Prograf dose was decreased, he will be followed tomorrow at the Renal Transplant Clinic.
Keywords: discharge summary, end-stage renal disease, cadaveric kidney transplant, cadaveric renal transplant, blood pressure, hemodialysis, esrd, pressure, prograf, transplant, renal,