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Hospital Discharge Report
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Synthesis
Coronary artery disease confirmed on imaging, management plan established
Hospital course note
Dear colleague, thank you for referring this 81-year-old female patient who was admitted
on 2014-08-01 for evaluation of abnormal findings on cardiac imaging. Following admission,
she underwent comprehensive cardiac assessment including resting ECG, echocardiography,
and coronary CT angiography, which confirmed the presence of significant coronary
artery disease with evidence of atherosclerotic changes in multiple vessels. Cardiac
biomarkers were measured and remained within normal limits, excluding acute myocardial
infarction. A structured management plan was established in consultation with our
cardiology team, including initiation of optimised medical therapy comprising antiplatelet
therapy, statin, and beta-blocker. The patient remained haemodynamically stable throughout
her stay. She is discharged home in a satisfactory condition with outpatient cardiology
follow-up arranged. Please ensure medication adherence and cardiovascular risk factor
monitoring at your earliest convenience.
Diagnosis at Discharge
| Abnormal findings on diagnostic imaging of heart and coronary circulation | 02-Aug-2014 | active |
Significant procedures
| Beta-blocker therapy initiated | 02-Aug-2014 | - |