Sample Report: Discharge Summary: Posttraumatic Aortic Pseudoaneurysm
REASON FOR ADMISSION: Posttraumatic chest discomfort.
HISTORY OF PRESENT ILLNESS: The patient is a middle-aged male who enjoyed good health until approximately 3 weeks ago when he was kicked in the area of his right chest by his horse. Following that, he experienced unremitting chest discomfort.
PHYSICAL EXAMINATIONS: His physical examination was within normal limits except for discomfort over the right chest area. See his chart for details of physical findings.
LABORATORY DATA: Laboratory values were all within normal limits.
STUDIES: Chest x-ray revealed a well-defined middle mediastinal mass. On the lateral view, the mass appeared to overlap the aorta. Rib fractures were noted on the right side. CT scan revealed a focal outpouching of the aorta with surrounding thrombus, consistent with an aortic pseudoaneurysm, most likely posttraumatic.
HOSPITAL COURSE: The patient was advised of the findings and that immediate surgical intervention was necessary to avoid possible rupture and even death.
Aneurysmectomy was performed without complication, and he has done remarkably well following surgery. The patient is discharged on postoperative day 5. He is to rest at home and will be seen in my office in 2 days.
DISCHARGE MEDICATION: Tylenol Extra Strength as needed for discomfort.