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Hospital Discharge Report

Patient
Name: Lefèvre, Roger
DOB: 26-JUN-1944 (Age: 81)
Gender: male
ID: 4279-145450-9
Author
family_name, given_name
Hospital Discharge Report
Report Date: 08-JUL-2018
Hospital Admission: --
Hospital Discharge: --

Synthesis

NSTEMI, treated with PCI

Hospital course note

Dear colleague, I am writing to inform you regarding our mutual patient, an 81-year-old male, admitted on 06/07/2018 presenting with acute chest pain and dyspnoea. Initial ECG showed no ST-elevation; however, serial troponin measurements were significantly elevated, confirming a Non-ST-Elevation Myocardial Infarction (NSTEMI). The patient was commenced on dual antiplatelet therapy, anticoagulation, and supportive medication. Urgent coronary angiography revealed significant coronary artery disease, and percutaneous coronary intervention (PCI) was successfully performed with stent implantation. Post-procedurally, the patient remained haemodynamically stable without complications. He was discharged on 08/07/2018 on dual antiplatelet therapy, statin, ACE inhibitor, and beta-blocker. Please ensure medication compliance and arrange cardiology follow-up within four weeks. Do not hesitate to contact me should you require further information.

Medications

2018-07-08 - - -

Diagnosis at Discharge

Acute subendocardial myocardial infarction 08-Jul-2018 active

    Significant procedures

    Risk assessment (procedure) 06-Jul-2018 -