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Hospital Discharge Report

Patient
Name: Zaczyk, Piotr
DOB: 25-JUN-1970 (Age: 55)
Gender: male
ID: 8035-929440-4
Author
dr Lubera, Łukasz
Hospital Discharge Report
Report Date: 01-FEB-2006
Hospital Admission: --
Hospital Discharge: --

Synthesis

Coronary artery disease confirmed on imaging, management plan established

Hospital course note

Dear colleague, I am writing to inform you regarding our mutual patient, a 55-year-old male admitted on 31/01/2006 due to abnormal findings on cardiac imaging. Following admission, the patient underwent comprehensive cardiac evaluation including resting ECG, echocardiography, and coronary angiography, which confirmed the presence of significant coronary artery disease. Findings demonstrated evidence of coronary arterial narrowing consistent with atherosclerotic disease. During the inpatient stay, the patient was stabilised medically with initiation of antiplatelet therapy, statin, and beta-blocker. A structured management plan was established including lifestyle modification counselling and cardiac rehabilitation referral. The patient was discharged in a stable condition on 01/02/2006. We kindly request your continued follow-up, monitoring of cardiovascular risk factors, and medication adherence. Please do not hesitate to contact us should you require further information.

Diagnosis at Discharge

Abnormal findings on diagnostic imaging of heart and coronary circulation 01-Feb-2006 active

    Significant procedures

    Lifestyle modification and cardiac rehabilitation counselling 01-Feb-2006 -