[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-307572-105":53,"doc-detail-307572-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","good-discharge-summary-sample-medicine","Good Discharge Summary Sample - Medicine","","General internal medicine discharge summary for an inpatient diagnosed with pyelonephritis complicated by acute kidney injury and transaminitis. The record documents admission and discharge dates, key comorbidities affecting length of stay, clinical course including sepsis-related hypotension and elevated lactate, diagnostic findings (E. coli bacteremia, enlarged prostate), and treatments such as IV fluids, hemodynamic support, antibiotics, and tamsulosin. It concludes with discharge medications, follow-up instructions for symptoms and lab reassessment.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/good-discharge-summary-sample-medicine/307572/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/good-discharge-summary-sample-medicine/307572.png","ImageObject",442,249,{"name":88,"@type":89},"Alex Sinclair","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What was the primary diagnosis at discharge, and what complications were documented?","Question",{"text":109,"@type":110},"The discharge diagnosis was pyelonephritis. Complications included acute kidney injury and transaminitis.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How was hypotension and elevated lactate managed during the hospital stay?",{"text":114,"@type":110},"The patient received IV fluids (bolus), ICU consultation, an arterial line for hemodynamic monitoring, and hemodynamic support with levophed and crystalloids. Lactate normalized and hemodynamics stabilized after about 12 hours.",{"name":116,"@type":107,"acceptedAnswer":117},"Which follow-up testing and symptom monitoring were requested after discharge?",{"text":118,"@type":110},"The family physician was asked to repeat AST and ALT in two weeks to ensure normalization. The patient was advised to urgently contact the family doctor or visit the emergency department if fever and urinary symptoms return, and to contact the physician if dizziness occurs after starting the new prostate medication.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},307572,1790454163,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},1099523882182,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","SAMPLE  \nPage 1 of 3  \nGENERAL INTERNAL MEDICINE DISCHARGE SUMMARY  \nPatient Name: Smith, John DOB: 25-Dec-1950, 65 years old  \nMRN: 1234567 Gender: Male  \nVISIT ENCOUNTER  \nVisit Number: 11186424686  \nAdmission Date: 08-Oct-2015  \nDischarge Date: 14-Oct-2015  \nDischarge Diagnosis: Pyelonephritis  \nPrimary Care Provider / Family Physician: Most Responsible Health Care Provider: Discharge Summary Completed by:  \nEnsure Primary Care / Referring Provider information is correct  \nJay, Samantha; 416-555-5555  \nSnow, Michael; Physician; 416-123-4567  \nLee, Dan; Senior Resident; 416-321-4567 on 23-Jul-2015  \nPatient Encounter Type: Inpatient  \nDischarge Disposition: Discharged home from Toronto General Hospital (General Internal Medicine)  \nDIAGNOSIS (Co-Morbidities and Risks)  \nConditions Impacting Hospital LOS:  \nPre-Existing:  \n• Hypertension, Type 2 diabetes with no known complications  \nDeveloped:  \n• Acute kidney injury, Transaminitis  \nBe concise and itemize descriptions of patient’s initial presentation  \nConditions Not Impacting LOS:  \n• Iron deficiency anemia  \nRisks: None  \nCOURSE WHILE IN HOSPITAL  \nIndicate pre-existing conditions patient arrived with vs. conditions that developed during stay  \nRelevant Complaint(s) and Concerns:  \n1.  Upon arrival: Patient presented with five days of increased urinary frequency, urgency and dysuria as well as  \n48 hours of fever and rigors. He was hypotensive and tachycardic upon arrival to the emergency department. The internal medicine service was consulted. The following issues were addressed during the hospitalization:  \nSummary Course in Hospital (Issues Addressed):  \n2.  Fever and urinary symptoms: A preliminary diagnosis of pyelonephritis was established. Other causes of fever were possible but less likely. The patient was hypotensive on initial assessment with a blood pressure of 80/40 . Serum lactate was elevated at 6.1. A bolus of IV fluid was administered (1 .5L) but the patient remained hypotensive. Our colleagues from ICU were consulted. An arterial line was inserted for hemodynamic monitoring. Hemodynamics were supported with levophed and crystalloids. Piptazo was started after blood and urine cultures were drawn. After 12 hours serum lactate had normalized and hemodynamics had stabilized. Blood cultures were positive for E.Coli that was sensitive to all antibiotics. The patient was stepped down to oral ciprofloxacin to complete a total 14 day course of antibiotics.  \nOn further review it was learned that the patient has been experiencing symptoms of prostatism for the last year. An abdominal ultrasound performed for elevated liver enzymes and acute kidney injury confirmed a  \nPrinted by: Snow, Mike on 15-OCT-2015  \nseverely enlarged prostate. Urinary retention secondary to BPH was the likely underlying mechanism that contributed to the development of pyelonephritis in this patient. He was started on Tamsulosin 0.4mg PO qhsand tolerated it well with no orthostatic intolerance. Post void residuals show 150-200cc of retained urine in the bladder. An outpatient referral to Urology has been requested by our team.  \n3.  Elevated liver enzymes and creatinine. Both of these were thought to be related to end organ hypoperfusion in the setting of sepsis. Values improved with the administration of IV fluid and stabilization of the patients hemodynamics. Abdominal ultrasound with doppler flow and urine analysis ruled out other possible etiologies. Liver enzymes remain slightly above normal values at the time of discharge. We ask that the  \npatients’ family physician repeat these tests in 2 weeks’ time to ensure complete resolution.  \nInvestigations:  \nLabs  \nInclude important developments while in hospital (do not be over-inclusive)  \n\n|  | Test | Test Date | Results | Units |\n| --- | --- | --- | --- | --- |\n| 1 | Lactate | 08-Oct-2015 | 6.1 | mmol/L |\n| 2 | ALP | 08-Oct-2015 | 450 | IU/L |\n| 3 | ALT | 08-Oct-2015 | 1001 | IU/L |\n| 4 | AST | 08-Oct-2015 | 850 | IU/L |\n| 5 | Bilirubin","cbCaijQA1eV8JRra","https://ap.wps.com/l/cbCaijQA1eV8JRra","pdf",533318,"English","# Patient Information\n## Visit and Admission/Discharge Details\n# Diagnosis and Risk Assessment\n## Co-morbidities and Conditions Impacting Length of Stay\n# Hospital Course\n## Fever and Urinary Symptoms\n## Elevated Liver Enzymes and Creatinine\n# Investigations\n## Labs\n## Radiology\n# Interventions and Allergies\n# Discharge Plan\n## Medications at Discharge\n## Follow-Up Instructions for Patient\n## Follow-Up Plan for Receiving Providers","[{\"question\":\"What was the primary diagnosis at discharge, and what complications were documented?\",\"answer\":\"The discharge diagnosis was pyelonephritis. Complications included acute kidney injury and transaminitis.\"},{\"question\":\"How was hypotension and elevated lactate managed during the hospital stay?\",\"answer\":\"The patient received IV fluids (bolus), ICU consultation, an arterial line for hemodynamic monitoring, and hemodynamic support with levophed and crystalloids. Lactate normalized and hemodynamics stabilized after about 12 hours.\"},{\"question\":\"Which follow-up testing and symptom monitoring were requested after discharge?\",\"answer\":\"The family physician was asked to repeat AST and ALT in two weeks to ensure normalization. The patient was advised to urgently contact the family doctor or visit the emergency department if fever and urinary symptoms return, and to contact the physician if dizziness occurs after starting the new prostate medication.\"}]","Good Discharge Summary Sample - Medicine | PDF",1789851254]