Admission Diagnosis: List primary diagnosis treated this time
Discharge Diagnosis: List other preadmission & post-admission diagnoses.
History of presenting illness: How patient presented to the hospital.
Initial Physical exam: Include Vitals and Glucose here
Investigations: Initial and subsequent investigations including lab work, cultures, imaging, etc… and summary results from these investigations.
Course in Hospital: List each issue and how it was managed, example:
"This patient was admitted with cellulitis, elevated blood sugar and acute kidney injury. Issues were as follows:
1) Cellulitis and abscess: Arm US showed abscess which was drained by interventional radiology on March 11. He was treated with antibiotics (initially cefazolin but changed to vancomycin on March 12 once culture results available. Both blood and abscess cultures grew MRSA. He was followed by infectious diseases in the hospital (Dr G Rose). An echocardiogram was done to look for signs of endocarditis and was normal. He will finish another week of antibiotics and see infectious diseases for reassessment.
2) Acute kidney injury: likely due to pre-renal due to infection, poor oral intake and hyperglycemia. He was treated with iv fluids and his creatinine slowly normalized. He was also using ibuprofen for pain at home and we recommend he discontinue this as it can contribute to kidney injury.
3) Diabetes: Patients blood sugars were uncontrolled initially. He met the dietician and diabetic nurse educator and was started on gliclazide in addition to metformin which he was on previously. We have sent a referral to endocrinology (Dr Dora Liu) for further care. On discharge his blood sugars were 7-10."
Include physical exam and vitals at time of discharge.
Preadmission medications to be stopped:
Preadmission medication to be continued:
Management Plan and Recommendations:
List instruction to family doctor
Follow up instructions
When to return to hospital