MRN: 123-45-67 Name : John Smith DOB: 1955-09-07 Sex : M
Discharge Summaries Report
ADMITTED:  00/00/94

OPERATION DATE:

DISCHARGED:  00/00/94

HISTORY OF PRESENT ILLNESS:
The patient is a 91 year old man who has a history of
hypertension, prostate cancer, transitional cell carcinoma of the
bladder and Paget's disease of the pelvis.  He occasionally drinks
alcohol.  He was brought to Area A on the day of admission after
falling out of bed and was unable to sit or stand for 4 hours.
His only medications are Procardia XL 30 a day, Hygroton 50 a day.

PHYSICAL EXAMINATION:
His physical examination revealed no signs of trauma, blood
pressure 110/70, heart rate 80 and regular, temperature 97.  His
skin was dry.  Right cornea was scarred, chronically.  He has no
jugular venous distention, no bruits.  Lungs were clear.  Heart
revealed a regular S1, S2, no murmur.  Abdomen is benign.
Neurological examination shows that he is generally weak,
bilateral and symmetric.  When seen on the floor, he is unable to
stand unless the person assists him.

LABORATORY DATA:
The laboratory data on admission is white blood cell count 14.7,
hematocrit 33, serum sodium was 147, potassium 4.8, chloride 110,
bicarbonate 21, BUN 40, creatinine 1.5.  This is unchanged from
baseline.  His PSA is 44, consistent with the diagnosis of
prostate cancer.

HOSPITAL COURSE:
The patient was observed in the hospital.  There were no episodes
of syncope.  CT scan of the head revealed no signs of
intracerebral bleeding.  A Holter monitor was obtained.  The
report is pending at the time of discharge.  He was seen by
physical therapy to help in gait assistance and at the time of
discharge was able to ambulate independently for several feet.

FINAL DIAGNOSIS:              CEREBROVASCULAR DISEASE,
                              HYPERTENSION, OSTEOARTHRITIS,
                              PAGET'S DISEASE, PROSTATE CANCER.

DICTATED BY:  Well-known Doctor, M.D.

ATTENDING:    Well-know Doctor, M.D.