Medical Transcription Discharge Summary Sample # 1:
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
1. Vasovagal syncope, status post fall.
BRIEF HISTORY: The patient is an (XX)-year-old female with history of previous stroke; hypertension; COPD, stable; renal carcinoma; presenting after a fall and possible syncope. While walking, she accidentally fell to her knees and did hit her head on the ground, near her left eye. Her fall was not observed, but the patient does not profess any loss of consciousness, recalling the entire event. The patient does have a history of previous falls, one of which resulted in a hip fracture. She has had physical therapy and recovered completely from that. Initial examination showed bruising around the left eye, normal lung examination, normal heart examination, normal neurologic function with a baseline decreased mobility of her left arm. The patient was admitted for evaluation of her fall and to rule out syncope and possible stroke with her positive histories.
DIAGNOSTIC STUDIES: All x-rays including left foot, right knee, left shoulder and cervical spine showed no acute fractures. The left shoulder did show old healed left humeral head and neck fracture with baseline anterior dislocation. CT of the brain showed no acute changes, left periorbital soft tissue swelling. CT of the maxillofacial area showed no facial bone fracture. Echocardiogram showed normal left ventricular function, ejection fraction estimated greater than 65%.
1. Fall: The patient was admitted and ruled out for syncopal episode. Echocardiogram was normal, and when the patient was able, her orthostatic blood pressures were within normal limits. Any serious conditions were quickly ruled out.
DISCHARGE DISPOSITION: Discharged to skilled nursing facility.
ACTIVITY: Per physical therapy and rehabilitation.
DIET: General cardiac.
MEDICATIONS: Darvocet-N 100 one tablet p.o. q.4-6 h. p.r.n. and Colace 100 mg p.o. b.i.d. Medications at Home: Zestril 40 mg p.o. daily, Plavix 75 mg p.o. daily, Norvasc 5 mg p.o. daily, hydrochlorothiazide 50 mg p.o. daily, potassium chloride 40 mEq p.o. daily, Atrovent inhaler 2 puffs q.i.d., albuterol inhaler 2 puffs q.4-6 h. p.r.n., clonidine 0.1 mg p.o. b.i.d., Cardura 2 mg p.o. daily, and Macrobid for prophylaxis, 100 mg p.o. daily.
1. Follow up per skilled nursing facility until discharged to regular residence.
2. Follow up with primary provider within 2-3 weeks on arriving to home.
Medical Transcription Discharge Summary Sample # 2:
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMITTING DIAGNOSIS: Syncope.
CHIEF COMPLAINT: Vertigo or dizziness.
HISTORY OF PRESENT ILLNESS: This is an (XX)-year-old male with a past medical history of coronary artery disease, CABG done a few years ago, atrial fibrillation, peripheral arterial disease, peripheral neuropathy, recently retired one year ago secondary to leg pain. The patient came to the ER for an episode of vertigo while reaching for some books. The patient was able to reach the books, to support self, but did not have any syncope. No nausea or vomiting. No chest pain. No shortness of breath. Came to ER and had a CT head, which was within normal limits. The impression was atrophy with old ischemic changes but no acute intracranial findings. No focal weakness, headache, vision changes or speech changes. The patient has had similar episodes since one year. Peripheral neuropathy since one year and not relieved with multiple medications. The patient also complains of weight loss of 25 pounds in the last 6 months. No colonoscopy done. Recent history of hematochezia but believes it was secondary to proctitis and secondary to decreased appetite. No nausea, vomiting, no abdominal pain.
PROCEDURES PERFORMED: The patient had a chest x-ray, which showed cardiomegaly with atherosclerotic heart disease, pleural thickening and small pleural effusion, a left costophrenic angle which has not changed when compared to prior examination, COPD pattern. The patient also had a head CT which showed atrophy with old ischemic changes. No acute intracranial findings.
CONSULTS OBTAINED: A rehab consult was done.
PAST MEDICAL/SURGICAL HISTORY: Positive for atrial fibrillation. The patient had AVR 6 years ago. Peripheral arterial disease with hypertension, peripheral neuropathy, atherosclerosis, hemorrhoids, proctitis, CABG, and cholecystectomy.
FAMILY HISTORY: Positive for atherosclerosis, hypertension, autoimmune diseases in the family.
SOCIAL HISTORY: Never smoked. Alcohol socially. No drugs.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
REVIEW OF SYSTEMS: Weight loss of 25 pounds within the last 6 months, shortness of breath, constipation, bleeding from hemorrhoids, increased frequency of urination, muscle aches, dizziness and faintness, focal weakness and numbness in both legs, knees and feet.
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 188/74, pulse 62, respirations 18 and saturation of 98% on room air. General Appearance: The patient is a pleasant man, comfortable. HEENT: Conjunctivae are normal. PERRLA. EOMI. NECK: No masses. Trachea is central. No thyromegaly. LUNGS: Clear to auscultation and percussion bilaterally. HEART: Irregular rhythm. ABDOMEN: Soft, nontender, and nondistended. Bowel sounds are positive. GENITOURINARY: Prostate is hypertrophic with smooth margin. EXTREMITIES: Upper and lower limbs bilaterally normal. SKIN: Normal. NEUROLOGIC: Cranial nerves are grossly within normal limits. No nystagmus. DTRs are normal. Good sensation. The patient is alert, awake, and oriented x3. Mild confusion.
LABORATORY DATA AND RADIOLOGICAL RESULTS: WBC 8.6, hemoglobin 13.4, hematocrit 39.8, platelets 207,000, MCV 91.6, neutrophil percentage of 72.6%. Sodium 133, potassium 4.7, chloride 104. Blood urea nitrogen of 18 and creatinine of 1.1. PT 17.4, INR 1.6, PTT 33.
The patient had a chest x-ray, which showed cardiomegaly with atherosclerotic heart disease, pleural thickening and small pleural effusion, a left costophrenic angle which has not changed when compared to prior examination, COPD pattern. The patient also had a head CT, which showed atrophy with old ischemic changes. No acute intracranial findings.
HOSPITAL COURSE AND TREATMENT: This is an (XX)-year-old male with syncope.
1. Syncope. This may be secondary to questionable cerebral ischemia/atrial fibrillation/hypotension, so Neurology was kept on board and the patient was scheduled for a carotid Doppler and a 2-D echo. Orthostatics were ordered. Vitamin B12, TSH, free T4 and T3 were ordered along with cortisol level in the morning. FOBT x3 were done and cardiology followup as outpatient. The patient had a carotid Doppler done on the next day and it showed mild irregular plaque disease, right and left internal carotid arteries, approximately 20-59%. The patient's vitamin B12 level came the next morning and the level was 1180. His folate was 18.7 and his TSH was 1.98, free T4 of 1.38 and T4 level of 7.4, cortisol level of 15.4, which are within normal limits. Dr. Doe, who is the patient's cardiologist, was informed. Dr. Doe was kind enough to see the patient the very next day, and his impression was that the patient has atrial fibrillation, rate controlled, status post AVR, St. Jude, and peripheral neuropathy. Subtherapeutic INR, the patient's relative target INR is 2-3. He suggested PT evaluation and suggested a low dose of SSRI and Dr. Doe was of the opinion that the patient does not need any further cardiac recommendation. CT chest, abdomen, and pelvis were done. CT chest had an impression of coronary artery calcification, aortic valve replacement, cardiomegaly, suspect a very small left pleural effusion, no acute active pulmonary disease. CT abdomen and pelvis showed prior cholecystectomy, diverticulosis of sigmoid colon, two benign-appearing simple cysts involving the right kidney, calcified arteriosclerotic plaque disease of the abdominal aorta and iliac vessels bilaterally. The patient was ruled out of any malignancy whatsoever.
2. Hypertension. The patient at home was on Cardizem ER 90 mg thrice daily, and it was changed initially to Cardizem 90 mg thrice daily, and then with Dr. Doe's request, we changed the Cardizem to 240 mg t.i.d.
3. Atrial fibrillation with subtherapeutic INR. The patient at home was on Digitalis. That was continued. Dr. Doe was of the opinion that the patient himself takes care of the Coumadin, and Dr. Doe was of the opinion that probably that is why the patient is not able to maintain therapeutic INR. In the hospital, the patient's warfarin was increased to 5 mg q.h.s., and at the time of the discharge, he was requested to follow his appointments so that his INR can be maintained.
4. Gout. The patient was on allopurinol. There were no acute issues regarding the gout.
5. Prophylaxis. The patient was on Protonix and TEDs.
6. Social. The patient is FULL CODE.
DISCHARGE DIAGNOSIS: Syncope.
DISCHARGE DISPOSITION: The patient is discharged to home.
DISCHARGE MEDICATIONS: The patient was discharged on the following medications; Cardizem 90 mg p.o. thrice daily, digoxin 0.125 mg p.o. once daily, allopurinol 100 mg two times daily, Coumadin 4 mg p.o. q.h.s., and Remeron 15 mg p.o. q.h.s.
DISCHARGE INSTRUCTIONS: Since the patient had generalized deconditioning, the patient was advised home PT, OT and that was arranged for the patient.
DISCHARGE DIET: Cardiac diet.
DISCHARGE ACTIVITY: Resume activity as tolerated.
Medical Transcription Discharge Summary Sample Report # 3
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
1. Fever, secondary to abdominal wall cellulitis and abscess in the abdomen.
2. Short bowel syndrome.
3. Crohn's disease.
8. Deep venous thrombosis.
9. Methicillin-resistant Staphylococcus aureus infection.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old Hispanic female was admitted for fever, hypotension and back and right shoulder pain after a fall at the nursing home. Temperature was as high as 102.4. The patient has been hospitalized several times for similar problems. She has Crohn's disease. She has had a recent bowel resection. She has been having problems with short bowel syndrome because essentially the whole ileum has been removed. She has a jejunostomy.
PHYSICAL EXAMINATION: The patient appears cushingoid. She has a jejunostomy.
HOSPITAL COURSE: The patient was put on IV fluids and given hydrocortisone, Flagyl, Compazine, Imuran, Protonix, Pentasa, dicyclomine, Xanax, Restoril, lidocaine patches, Wellbutrin, trazodone, Cymbalta, Lexapro, Neurontin and subcutaneous heparin. Her creatinine was elevated at 2.6. Hemoglobin was 10.2. Imuran was held. The patient was seen by the pain service. She was given IV Dilaudid as needed. She was started on food. Hemoglobin 9.6, albumin 1.8, magnesium 1.6, phosphorus 3.6. Troponins were less than 0.4 x2. Chest x-ray showed satisfactory PICC position. Blood cultures x2 showed no growth. Urine C&S showed no growth. The patient was started on a taper of hydrocortisone. Imuran was restarted. She was seen by Psychiatry. Creatinine was down to 1.2. The patient was transferred out of the intensive care unit. She was continued on Claforan, Flagyl and Diflucan. On MM/DD/YYYY, hemoglobin was 9.2. Hydrocortisone was discontinued and she was put on prednisone. She was seen by Dr. Doe who recommended TobraDex t.i.d. for 1 week. On MM/DD/YYYY, renal ultrasound was negative. CT showed increased small bowel thickening. The patient's fever resolved. On MM/DD/YYYY, hemoglobin was 10.8. The patient was put on IV heparin because of ultrasound of the upper extremity showing deep venous thrombosis in the cephalic vein on the right. Solu-Medrol was discontinued on MM/DD/YYYY. She was put on prednisone. Dr. Doe had scoped the jejunum and found copious mucus and mild colitis. The jejunum was normal to 40 cm. The patient had heartburn but that was improved. On MM/DD/YYYY, Foley catheter was discontinued. Physical and occupational therapy was ordered, but the patient could not tolerate it because of abdominal pain. On MM/DD/YYYY, stool for Clostridium difficile was negative. The patient received transfusion. Wound C&S grew light growth with MRSA and the patient was started on vancomycin. Attempt to drain the abdominal cavity revealed no drainage. The patient was complaining of pain in her hand. She was seen by Dr. Jane Doe who did not find any active disease. The patient's INR was well controlled on Coumadin, so the heparin has been discontinued. On MM/DD/YYYY, chest x-ray showed satisfactory PICC position. The patient fell and injured her knees on MM/DD/YYYY. X-ray of the left knee showed mild degenerative changes. X-ray of the right knee showed small bony density along the articular surface of the proximal anterior tibia and mild degenerative changes. The patient has an episode of hypotension, 84/48, on MM/DD/YYYY. Amlodipine was discontinued, metoprolol was decreased. She was put back on IV fluids. On MM/DD/YYYY, white count was 4600, hemoglobin 10.2, INR 2.18. Electrolytes were normal. Glucose was 142. The patient continues to have abdominal pain requiring IV fluids because of the large jejunostomy output. Last blood pressure on MM/DD/YYYY was 94/50. Abscess fungal culture was negative on MM/DD/YYYY and MM/DD/YYYY. Myelin-associated glycoprotein was negative. Calcium on MM/DD/YYYY was 8.2.
PLAN: Transfer the patient to an expert in short bowel syndrome. She will be on dicyclomine 20 mg q.6 h., tizanidine 4 mg b.i.d., lidocaine patch to the lower back and left shoulder 12 hours on and 12 hours off, Wellbutrin XR 150 mg 2 tablets daily, trazodone 50 mg b.i.d., Cymbalta 30 mg q.a.m. 3 tablets so a total of 90 mg q.a.m., citalopram 10 mg q.a.m., fluconazole 200 mg daily, azathioprine 100 mg daily, metoprolol 50 mg b.i.d. hold for systolic blood pressure less than 120, Lomotil 2 tabs q.6 h., prednisone 5 mg daily. The patient is not on vancomycin. The patient is on tigecycline 50 mg q.12 h., Coumadin 5 mg at bedtime, Pentasa 1 gram p.o. q.i.d., Protonix 40 mg daily, Colestid 1 gram b.i.d., Lactinex 2 tabs b.i.d. The patient has Actiq by her bedside. She gets Dilaudid 0.2 mg IV p.r.n. and she is on Ambien 10 mg at bedtime for sleep.
Medical Transcription Discharge Summary Sample Report # 4:
DATE OF ADMISSION:
DATE OF DISCHARGE:
1. Status asthmaticus.
2. Bronchiolitis, empirically treated.
BRIEF HISTORY: The patient is a (XX)-year-old white female with known history of asthma since infancy, possible environmental allergies, who presented with progressive wheezing and respiratory distress for the past two days. The patient had been doing well on only p.r.n. medications per family's report. However, just previous to admission, the patient was exposed to dust and other particles after moving into a new house. After conservative treatment at home, the patient was brought into the emergency room where she did not improve on albuterol, Atrovent treatments or intravenous steroids immediately. Initial examination showed tachycardia of 128, rest tachypnea of about 35-40, inspiratory and expiratory wheezes and rhonchi on lung examination. The patient was referred for admission for evaluation of worsening asthma and possible pneumonia.
STUDIES: The admission chest x-ray showed clear lungs. Clean catch urine culture showed only mixed skin flora.
1. Status asthmaticus: The patient was admitted to the pediatric intensive care unit in moderate to severe respiratory distress with continuous albuterol treatments, Atrovent treatments q.4 h., Decadron intravenously and empiric treatment of respiratory infection with azithromycin intravenously. The patient responded to this aggressive treatment and within one day was transferred to the regular pediatric medical floor. The patient was afebrile with normal oxygen saturations and appearing much better. Before discharge, she received asthma education and social counseling along with the family and was connected with social work to help provide a home nebulizer for use.
2. Empiric respiratory infection treatment: The patient did not show any specific indications of pneumonia or bronchitis by lab work; however, her initial physical examination showed possible pneumonia. She was started on intravenous antibiotics and was transferred to oral antibiotics before discharge.
DISCHARGE DISPOSITION: To home.
ACTIVITY: Ad lib.
DIET: Regular, as appropriate for age.
MEDICATIONS: Zithromax for two remaining days, albuterol one dose nebulizer treatment q.i.d. and p.r.n. and Flovent 110 mcg 2 puffs b.i.d.
FOLLOWUP: Follow up with primary care physician in 1 week.