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Patient Name: Pat Hernandez   DOB: 05/05/19XX

Address: 555 River Rd., Columbus, OH 43210  Phone: 614-555-5555

Medication Allergies: NKDA

Discharge Summary

Pat is a pleasant 62-year-old who was admitted to the hospital 5 days ago after presenting with a several day history of worsening lower extremity edema, SOB, and cough. The patient was found to be in acute exacerbation of chronic systolic heart failure with acute kidney injury (AKI). The patient’s home ARB and potassium were stopped due to AKI/hyperkalemia upon presentation. Metformin was also held during admission. While receiving IV diuresis, the pt became hypotensive and bradycardic. Cardiology was consulted and recommended holding the home BB while continuing gentle diuresis. After normalization of fluid status, the BB was restarted at half of the home dose per recommendation from cardiology, which the pt tolerated well. AKI resolved with SCr trending near baseline currently. At discharge, the pt has been instructed to hold Diovan and continue adjustments to the doses of Coreg and Lasix made during admission. Pt will continue to take potassium supplement as an outpatient due to increased dose of Lasix. The pt will follow up with PCP in 1 week to monitor blood pressure, fluid status, and electrolytes. Due to multiple changes, the patient will receive counseling from our pharmacist on med changes prior to discharge.

PMH

HTN, HF with ejection fraction of 30%, T2DM

Vitals/Labs at Discharge

BP 102/60 mmHg, HR 64 bpm, Wt 109 kg, K 4.8 mEq/L, Na 142 mEq/L, SCr 1.03 mg/dL, BUN 9 mg/dL, Cl 100 mEq/L, CO2 24 mEq/L

Patient Medication Instructions

STOP taking the following medications

  • Valsartan (Diovan) 80 mg

    • Other information: Follow up with your PCP about this medication.

CHANGE the way that you take the following medications

  • Carvedilol (COREG) 6.25 mg, Take one-half tablet by mouth twice daily.

    • What changed: How much to take

    • Other information: Check and record your blood pressure and heart rate daily. Follow up with your PCP about this medication.

  • Furosemide (LASIX) 40 mg, Take two tablets by mouth once daily every morning.

    • What changed: How much to take

    • Other information: Check and record your weight every morning. Follow up with your PCP about this medication.

CONTINUE these medications, which have NOT changed

  • Aspirin 81 mg, Take one tablet by mouth once daily.

  • Atorvastatin (LIPITOR) 80 mg, Take one tablet by mouth once daily.

  • Metformin ER (GLUCOPHAGE XR) 500 mg, Take two tablets by mouth twice daily.

  • Potassium chloride (KLOR-CON) 20 mEq, Take one tablet by mouth once daily.

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