Upload sample_docs/discharge_summary_001.txt

sample_docs/discharge_summary_001.txt

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+DISCHARGE SUMMARY
+Patient: John D. (MRN: 00123)
+Date of Admission: 2026-05-28
+Date of Discharge: 2026-06-02
+Attending Physician: Dr. Sarah Patel, MD
+
+PRIMARY DIAGNOSIS:
+Community-acquired pneumonia (CAP), right lower lobe.
+
+SECONDARY DIAGNOSES:
+- Type 2 Diabetes Mellitus (controlled)
+- Hypertension
+
+HOSPITAL COURSE:
+Mr. D. is a 62-year-old male who presented to the ED with a 4-day history of productive cough,
+fever (T 38.9°C), and shortness of breath. Chest X-ray confirmed right lower lobe consolidation.
+Blood cultures were drawn and sputum cultures sent. He was started on IV Ceftriaxone 1g q24h
+and Azithromycin 500mg daily. Repeat chest X-ray on Day 3 showed improvement. He was
+transitioned to oral Amoxicillin-Clavulanate 875mg/125mg BID on Day 4 and tolerated well.
+His blood glucose was monitored closely given his diabetic history; insulin sliding scale was used.
+He remained afebrile for 48 hours prior to discharge.
+
+MEDICATIONS AT DISCHARGE:
+1. Amoxicillin-Clavulanate 875mg/125mg — 1 tablet by mouth twice daily × 5 more days
+2. Metformin 1000mg — 1 tablet by mouth twice daily (home medication)
+3. Lisinopril 10mg — 1 tablet by mouth once daily (home medication)
+4. Aspirin 81mg — 1 tablet by mouth once daily (home medication)
+
+ALLERGIES:
+Penicillin — rash (mild). NOTE: Patient was given Amoxicillin-Clavulanate under observation;
+no adverse reaction observed during admission.
+
+FOLLOW-UP:
+- Primary Care (Dr. Patel): 1 week post-discharge — June 9, 2026
+- Pulmonology consult if symptoms recur
+
+DISCHARGE INSTRUCTIONS:
+- Complete the full antibiotic course.
+- Rest and increase fluid intake.
+- Return to ED if fever > 38.5°C, worsening shortness of breath, or hemoptysis.
+- Monitor blood glucose twice daily; target fasting glucose 80–130 mg/dL.
+- Do not drive while on any sedating medications.