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Active record: Asha Mehra · MV-102483

Discharge Summary

Discharge SummaryAsha Mehra · MV-102483 · Aug 18, 2026 · 3 pages
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Meridian General Hospital
Health Information Management · Synthetic demo record
MRN MV-102483
DOB May 17, 1964
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Inpatient Discharge Summary — Cardiology Service

Discharge Summary · Aug 18, 2026
Admission Date
Aug 14, 2026 · Discharge Date: Aug 18, 2026 · Length of stay: 4 days
Attending
Dr. L. Fernandes, MD — Cardiology · Ward 4B, Bed 12
Reason for Admission
Patient presented to the Emergency Department with progressive shortness of breath on exertion over five days, orthopnoea requiring two pillows, and bilateral ankle swelling. Admitted for management of acute decompensated heart failure.
History of Present Illness
62-year-old female with a background of essential hypertension and type 2 diabetes mellitus reported reduced exercise tolerance, nocturnal dyspnoea and a 3 kg weight gain in one week. No chest pain, syncope or palpitations. No fever or productive cough.
Past Medical History
Essential hypertension (12 years). Type 2 diabetes mellitus (8 years), diet and metformin controlled. Dyslipidaemia. No prior myocardial infarction. Non-smoker.
Scanned Aug 18, 2026 · Batch MV-A-DISCHARGE-1Confidential — fictional demonstration data
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Meridian General Hospital
Health Information Management · Synthetic demo record
MRN MV-102483
DOB May 17, 1964
Page 2 of 3

Hospital Course & Discharge Diagnosis

Discharge Summary · Aug 18, 2026
Discharge Diagnosis
1. Acute decompensated heart failure with reduced ejection fraction (HFrEF), NYHA class III on admission. 2. Essential hypertension. 3. Type 2 diabetes mellitus. 4. Stage 2 chronic kidney disease.
Hospital Course
Treated with intravenous furosemide 40 mg twice daily with a net negative fluid balance of 4.2 L over three days. Symptoms improved to NYHA class II. Transthoracic echocardiogram demonstrated left ventricular ejection fraction of 40% with global hypokinesis. BNP elevated at 892 pg/mL on admission, trending to 410 pg/mL at discharge.
Relevant Laboratory Findings
Creatinine mildly elevated at 1.42 mg/dL (baseline 1.20). Haemoglobin 10.9 g/dL. Potassium 3.4 mmol/L, corrected with oral supplementation. HbA1c 7.8%.
Discharge Plan
Discharged home in stable condition on oral diuretic and guideline-directed medical therapy. Daily weight monitoring, fluid restriction 1.5 L/day and 2 g sodium diet advised. Cardiology follow-up in 7 days with repeat renal panel. Return immediately if weight gain exceeds 2 kg in 48 hours or dyspnoea worsens.
Scanned Aug 18, 2026 · Batch MV-A-DISCHARGE-2Confidential — fictional demonstration data
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Meridian General Hospital
Health Information Management · Synthetic demo record
MRN MV-102483
DOB May 17, 1964
Page 3 of 3

Discharge Medications & Follow-up

Discharge Summary · Aug 18, 2026
Discharge Medications
Carvedilol 6.25 mg PO twice daily. Losartan 50 mg PO once daily. Furosemide 40 mg PO once daily in the morning. Metformin 500 mg PO twice daily with meals. Atorvastatin 20 mg PO at night. Potassium chloride 20 mEq PO once daily for 7 days.
Follow-up
Cardiology clinic in 7 days (Aug 25, 2026) with Dr. Fernandes. Repeat basic metabolic panel and BNP prior to visit. Heart failure nurse educator telephone review in 72 hours. Diabetes clinic in 4 weeks.
Electronically signed
Dr. L. Fernandes, MD — Aug 18, 2026, 16:42 · Transcribed by MedIT-OCR v4 (confidence 98.2%)
Scanned Aug 18, 2026 · Batch MV-A-DISCHARGE-3Confidential — fictional demonstration data
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