Identify the Principal Diagnosis Identify Secondary Diagnoses (where applicable) List…

Identify the Principal Diagnosis Identify Secondary Diagnoses (where applicable) List all Pharmaceutical Drugs Identify any Procedures Fill in the Condition Table Fill in the Drug Table Fill in the Procedure Table Discharge Summary Date of Admission: 11/19/XX Date of Discharge: 11/21/XX Discharge Diagnoses: 1. Anemia in chronic kidney disease 2. Chronic kidney disease, stage 3 3. Diabetes mellitus, Type 2 4. Hypertension 5. Coronary artery disease 6. Congestive heart failure 7.Hypokalemia Attending Physician for Service: Family Practice Service. Consultations: None. Procedures: None. Past Medical History: Obesity, Hypertension, Hypercholesteremia, Coronary Artery Disease Hospital Course: The patient is a 66-year-old male with multiple medical problems including coronary artery disease, diabetes mellitus, and chronic kidney disease, who presented to the emergency department at Anytown Hospital on 11/19/XX complaining of shortness of breath. He had been seen in the office earlier that week and seemed to be doing reasonably well at that point in time. On admission he said that over the past two to three days his shortness of breath had been increasing, and he had orthopnea and a nonproductive cough. He denied chest pain at that point in time. He denied other symptomatology. In the emergency department he was noted to have significant anemia with hemoglobin of 7.0 and a hematocrit of 21.2 with an MCV of 78.3. He was given two units of packed red blood cells via peripheral vein and admitted to the Transitional Care Unit to rule out myocardial infarction and to receive blood. Problems 1. Anemia. Initial H&H of 7.0 and 21.2. He received two units of packed red blood cells and at discharge his H&H was 9.1 and 27.0, respectively. His reticulocyte count was pending at discharge. Iron level was 51, total iron binding capacity was 371, and ferritin level was 14. He had been on iron as an outpatient. This was stopped secondary to diarrhea, which he felt was probably from the iron. We will restart this at this time consisting of Niferex one p.o. q. day. Follow his H&H as an outpatient. I would consider him for erythropoietin therapy at some point in time. 2. Cardiac. History of coronary artery disease and congestive heart failure. No past history of CABG. He had one elevated troponin on day one of hospitalization. He had two normal troponins previous to this and two post this. I am uncertain of the significance of this one elevation of his troponin to 1.6. He had no chest pain throughout. Electrocardiogram showed no changes. He was briefly started on heparin. This was subsequently discontinued the following day. We will send him home on his regular cardiac regimen consisting of Digoxin, an ACE inhibitor, diuretics consisting of Lasix and Carbatolol. He will also be given p.r.n. nitrates. From a congestive heart failure perspective on admission he was felt to have mild congestive heart failure. He diuresed wel