| 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 | |