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Discharge Summary Translation

An Indian hospital discharge summary translated for US continuity of care — with diagnosis codes mapped, medications converted to US-available equivalents, and lab values with unit conversions.


Source Document

Discharge Summary — Apollo Hospitals, Chennai

Patient: Rajesh Kumar Sharma | Age: 58 yrs / Male

MRN: APL-CHE-2026-84521 | Admission: 10/05/2026 | Discharge: 16/05/2026

Consultant: Dr. Priya Venkatesh, MD, DM (Cardiology)


Diagnosis

Primary: Acute ST-elevation MI (anterior wall)

ICD-10: I21.0

Secondary: Type 2 Diabetes Mellitus, uncontrolled

ICD-10: E11.65

Secondary: Essential Hypertension, Stage 2

ICD-10: I11.9

Procedure

PTCA with DES to LAD (12/05/2026)

Stent: Xience Sierra 3.0 x 28 mm

Discharge Medications

1. Tab. Ecosprin 75 mg OD

2. Tab. Clopivas 75 mg OD

3. Tab. Atorva 40 mg HS

4. Tab. Metolar XR 25 mg OD

5. Tab. Ramipril 5 mg OD

6. Inj. Lantus 18 units SC at bedtime

7. Tab. Glycomet GP 1 (500/1 mg) BD

Lab Values at Discharge

HbA1c: 8.9% | FBS: 186 mg/dL | PPBS: 264 mg/dL

Total Cholesterol: 242 mg/dL | LDL: 168 mg/dL | HDL: 34 mg/dL

Creatinine: 1.1 mg/dL | eGFR: 72 mL/min/1.73m²

Troponin I (peak): 18.4 ng/mL

TranslateMD Output

Discharge Summary — Apollo Hospitals, Chennai (India)

Patient: Rajesh Kumar Sharma | Age: 58 / Male

MRN: APL-CHE-2026-84521 | Admitted: 05/10/2026 | Discharged: 05/16/2026

Attending: Dr. Priya Venkatesh, MD, DM Cardiology (India)


Diagnosis

Primary: ST-elevation myocardial infarction involving left anterior descending artery

ICD-10-CM: I21.02

Secondary: Type 2 diabetes mellitus with hyperglycemia

ICD-10-CM: E11.65

Secondary: Hypertensive heart disease without heart failure

ICD-10-CM: I11.9

Procedure

PCI with drug-eluting stent to LAD (05/12/2026)

CPT: 92928 | Stent: Xience Sierra 3.0 x 28 mm (FDA-approved)

Discharge Medications

1. Aspirin (Ecosprin) 81 mg PO daily

2. Clopidogrel (Plavix) 75 mg PO daily

3. Atorvastatin (Lipitor) 40 mg PO at bedtime

4. Metoprolol succinate ER (Toprol-XL) 25 mg PO daily

5. Ramipril (Altace) 5 mg PO daily

6. Insulin glargine (Lantus) 18 units SC at bedtime

7. Metformin/Glimepiride (Glucovance+) 500/1 mg PO BID

Lab Values at Discharge

HbA1c: 8.9% | FBG: 186 mg/dL | 2h PPG: 264 mg/dL

Total Cholesterol: 242 mg/dL | LDL: 168 mg/dL | HDL: 34 mg/dL

Creatinine: 1.1 mg/dL | eGFR: 72 mL/min/1.73m²

Troponin I (peak): 18.4 ng/mL

Translation Annotations

Diagnosis Code Mapping

  • I21.0 (generic STEMI) → I21.02 (STEMI involving LAD) — more specific US coding
  • E11.65 — identical in both systems (diabetes with hyperglycemia)
  • I11.9 — identical in both systems (hypertensive heart disease)

Drug Name Mappings

  • Ecosprin 75 mg → Aspirin 81 mg (US standard low-dose)
  • Clopivas → Clopidogrel / Plavix (US brand)
  • Atorva → Atorvastatin / Lipitor
  • Metolar XR → Metoprolol succinate ER / Toprol-XL
  • Glycomet GP 1 → Metformin + Glimepiride combo
  • Lantus → Lantus (same globally)

Dosing Difference Alert

  • Aspirin: India uses 75 mg, US standard is 81 mg — adjusted per ACC/AHA guidelines
  • Both doses are considered equivalent low-dose antiplatelet therapy

Procedure & Format Notes

  • PTCA → PCI (preferred US terminology)
  • DES abbreviation expanded to 'drug-eluting stent'
  • Added CPT code 92928 for US billing
  • Date format: DD/MM/YYYY → MM/DD/YYYY
  • Indian abbreviations expanded (OD→daily, BD→BID, HS→at bedtime)

Lab Values

  • Units already in US-standard (mg/dL) — no conversion needed
  • FBS → FBG, PPBS → 2h PPG (US terminology)
  • All values within expected reference ranges for context

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