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DISCHARGE SUMMARY Patient: John Smith DOB: 1975-03-15 MRN: MR123456789 Admission Date: 2024-01-15 Discharge Date: 2024-01-18 CHIEF COMPLAINT: Chest pain and shortness of breath HISTORY OF PRESENT ILLNESS: 45-year-old male presents with acute onset chest pain radiating to left arm. Associated with diaphoresis and nausea. No prior cardiac history. VITAL SIGNS: Blood Pressure: 145/95 mmHg Heart Rate: 102 bpm Temperature: 98.6°F Oxygen Saturation: 96% on room air ASSESSMENT AND PLAN: 1. Acute coronary syndrome - rule out myocardial infarction 2. Hypertension - new diagnosis 3. Start aspirin 325mg daily 4. Lisinopril 10mg daily for blood pressure control 5. Atorvastatin 40mg daily MEDICATIONS PRESCRIBED: - Aspirin 325mg daily - Lisinopril 10mg daily - Atorvastatin 40mg daily - Nitroglycerin 0.4mg sublingual PRN chest pain FOLLOW-UP: Cardiology in 1 week Primary care in 2 weeks |