Ob-Gyn Discharge Summary Medical Transcription Sample Reports


DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY

ADMITTING DIAGNOSIS:  Intrauterine pregnancy at 38 weeks and 5 days.  Presented with contractions, leakage of fluid and decreased fetal movements that day.

HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE:  The patient is a (XX)-year-old G2, P0 female at 38 weeks and 5 days estimated gestational age who presented in labor.  On vaginal examination, the patient was found to be 4 cm dilated, 70% effaced and –3 station, and the fetal heart tracing at that time was in the 140s with minimal long-term variability.  She was admitted to Labor and Delivery for Pitocin augmentation and amniotomy.  She continued to have a good labor pattern and proceeded to deliver a viable 6-pound, 12-ounce male infant over an intact perineum with Apgars of 8 and 9 at one and five minutes.  There were no nuchal cords, no true knots and the number of vessels in the cord were three.  Her postpartum course was uncomplicated, and the patient was discharged to home in stable and satisfactory condition.

PROCEDURES PERFORMED:  Normal spontaneous delivery and Pitocin augmentation.

COMPLICATIONS:  None.

FINAL DIAGNOSIS:  Status post normal spontaneous vaginal delivery at 38 weeks and 5 days.

DISCHARGE INSTRUCTIONS:  Call for increased pain, fever or increased bleeding.

DIET:  Advance as tolerated.

ACTIVITY:  Advance as tolerated.  Pelvic rest for 6 weeks.  Nothing to be inserted into the vagina for 6 weeks, i.e. no tampons, douche or sex.

MEDICATIONS AND FOLLOWUP:  As per Dr. Doe.

 
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DATE OF ADMISSION: 

DATE OF DISCHARGE: 

ADMITTING DIAGNOSIS:  Intrauterine pregnancy at 36 weeks and 5 days estimated gestational age.  Presented with contractions and in latent labor.

DISCHARGE DIAGNOSIS:  Status post normal spontaneous vaginal delivery at 36 weeks and 5 days estimated gestational age.

HISTORY OF PRESENT ILLNESS/ HOSPITAL COURSE:  The patient is a (XX)-year-old G4, P 1-0-2-1 female at 36 weeks and 5 days estimated gestational age who presented with contractions and in latent labor.  On vaginal examination, the patient was found to be 3 cm dilated, 70% effaced and -3 station.  The fetal heart tracing at the time was in the 140s and reactive.  The patient was admitted to Labor and Delivery for antibiotics and epidural.  The patient continued to have a good labor pattern and proceeded to deliver a viable female infant weighing 5 pounds 7 ounces over an intact perineum with Apgars of 9 and 9 at one and five minutes.  There were no nuchal cords, no true knots and the number of vessels in the cord were three.  Her postpartum course was uncomplicated and the patient was discharged to home in stable and satisfactory condition on postpartum day #2.

PROCEDURES PERFORMED:  Normal spontaneous delivery and repair of midline episiotomy in the usual fashion.

COMPLICATIONS:  None.

FINAL DIAGNOSIS:  Status post normal spontaneous vaginal delivery at 36 weeks and 5 days estimated gestational age.

DISCHARGE INSTRUCTIONS:  Call for increased pain, fever or increased bleeding.

DIET:  Advance as tolerated.

ACTIVITY:  Pelvic rest for 6 weeks and nothing inserted into the vagina for 6 weeks, i.e. no tampons, douche or sex.

MEDICATIONS AND FOLLOWUP:  As per Dr. Doe.


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DATE OF ADMISSION: 

DATE OF DISCHARGE: 

DISCHARGE DIAGNOSES:

1.  Intrauterine gestation at term.
2.  History of two previous cesarean sections.
3.  Delivered viable male infant.
4.  Multiparity.  Fertility.  Desired sterilization.

PROCEDURES PERFORMED:

1.  Repeat low transverse cesarean section.
2.  Bilateral tubal ligation.

COMPLICATIONS:  None.

PERTINENT FINDINGS/HISTORY AND PHYSICAL:  Refer to the detailed admission dictation.

The patient is a (XX)-year-old gravida 6, now para 3-0-3-3 female, who was admitted at term for repeat cesarean section and sterilization.  The patient had previous cesarean sections for labor arrest, for an infant weighing 9 pounds 12 ounces and elective repeat.  The patient strongly desired repeat cesarean section.  She had been appropriately consented.  She had also wished to have a tubal ligation and signed the appropriate consent forms.  She is well aware of the risks, options, failure rates and permanency of sterilization procedures.  Her antenatal course was significant for development of A1 diabetes with blood sugars in excellent control, on diet only.  The patient declined genetic screening because of advanced maternal age.

LABORATORY INVESTIGATIONS:  Please refer to the admission dictation for the patient's antenatal labs.  The patient's admission hemoglobin was 11.1 with hematocrit of 33.4 and platelet count 196,000.  Her postoperative hematocrit was 32.2.

HOSPITAL COURSE:  The patient was admitted on the morning of her scheduled surgery.  Detailed informed consent was again reobtained.  All consents were signed.  Under spinal anesthesia, uncomplicated repeat low transverse cesarean section and bilateral tubal ligation were performed.  A viable male infant with Apgars of 9 and 9 with birth weight of 8 pounds 6 pounds was delivered.  The patient's postoperative course was uneventful.  She remained afebrile with stable vital signs.  She returned quickly to good ambulation and regular diet.  She had normal GI function return.  Her incision healed nicely.  Her lochia was light.

Discharge examination revealed negative HEENT, neck, heart, lung, extremities and abdominal examinations.

CONDITION ON DISCHARGE:  Stable.

DISPOSITION:  Discharged to home.

DISCHARGE INSTRUCTIONS:

ACTIVITY:  Slow increase as tolerated.  No heavy lifting.  Strict pelvic rest.

DIET:  Regular.

MEDICATIONS:  Colace p.r.n., Tylenol p.r.n. and prenatal vitamins.  The patient is breastfeeding.  Prescriptions for Percocet 325/5 tablets, #30, no refills, 1 to 2 p.o. q.4-6 h. p.r.n. pain and ibuprofen 800 mg, #20, no refills, 1 p.o. q.8 h. p.r.n. pain.

Follow up as an outpatient in the office in 1 week.

The patient has received routine verbal instructions and agrees to comply.  She knows to contact us immediately should she develop any signs or symptoms of complications such as fevers, chills, drainage from the incision, abdominal distention, nausea, vomiting, heavy vaginal bleeding, leg redness or swelling, chest pain, chest pressure or shortness of breath.
 


DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY 

HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE:  This is a (XX)-year-old gravida 1, para 0, at approximately 5 weeks estimated gestational age who presents with a diagnosis of ectopic pregnancy.  Ultrasound report showed a mass near the cul-de-sac.  The patient denies any medical or surgical history.  No known allergies.  Remaining history is noncontributory.  The patient was admitted for laparoscopic salpingectomy, removal of ectopic products of conception.  An operative laparoscopy was performed with a right salpingectomy performed, and the tissue was sent to pathology with final diagnosis of a right tubal ectopic pregnancy.

PROCEDURES PERFORMED:  Operative laparoscopy, right salpingectomy.

CONDITION:  Stable.

FINAL DIAGNOSIS:  Right tubal ectopic pregnancy.

DIET:  As tolerated.

PHYSICAL ACTIVITY:  No heavy lifting.  Pelvic rest.

MEDICATIONS AND FOLLOWUP:  As per Dr. Doe.

Delivery Note Transcribed Sample Report

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DATE OF ADMISSION: 

DATE OF DISCHARGE: 

HISTORY OF PRESENT ILLNESS/ HOSPITAL COURSE:  The patient is a (XX)-year-old G3, P2 at 38 weeks' gestation who presents secondary to spontaneous rupture of membranes.  The patient had had two previous C-sections and was admitted to Labor and Delivery for repeat low transverse C-section.  The patient underwent C-section delivering a viable female infant.  She was later transferred to postpartum and discharged to home on postpartum day #3.  There was noted to be a small amount of redness around the incision, so the patient was started on Keflex and it will be continued after discharge.

SIGNIFICANT FINDINGS:  A viable female infant with Apgars of 9 and 9, weight 5 pounds 14 ounces.

PROCEDURES PERFORMED:  Primary low transverse C-section.

FINAL DIAGNOSIS:  Status post repeat low transverse C-section.

CONDITION:  Stable.

DIET:  Regular.

PHYSICAL ACTIVITY:  Ad lib.

MEDICATIONS:  Keflex, Motrin and Percocet p.r.n.

FOLLOWUP:  Per Dr. Doe.

 
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DATE OF ADMISSION: 

DATE OF DISCHARGE: 

HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE:  This is a (XX)-year-old female, primigravida, who came in early labor.  The patient had been scheduled for a cesarean section due to breech presentation.  This patient has had no significant problems during first, second or third trimester.  The patient’s past medical history is noncontributory.  The patient’s LMP was MM/DD/YYYY, placing her EDC at MM/DD/YYYY.  Ultrasounds were performed throughout the pregnancy and revealed adequate growth during the pregnancy and EDC remained technically the same.  The patient’s initial blood work showed blood type to be A positive, VDRL nonreactive, rubella titer indicated immunity, hepatitis B surface antigen (HbsAg) was negative, HIV screen was negative, GC and Chlamydia cultures were negative.  Pap smear was normal.  Her 1-hour glucose tolerance test was within normal parameters.  The patient’s blood count also remained well within normal parameters.  Her quad screen for maternal serum alpha-fetoprotein (MSAFP) was normal.  Strep culture was likewise negative at 34-35 weeks.  The patient, upon admission, was having contractions approximately every 4-5 minutes, moderate in intensity.  The patient had no dilation, presenting part was still in a breech presentation, per bedside ultrasound, and the patient was therefore made ready for primary cesarean section.  The patient was taken to Surgery where primary cesarean section was performed with delivery of a breech infant from left sacral anterior positioning, female weighing 6 pounds 10 ounces with Apgars 8 and 8 at one and five minutes.  Placenta delivered intact.  Membranes were removed.  The patient tolerated the procedure quite well.  Estimated blood loss was less than 600 mL.  The patient has had an uneventful postoperative period.  She is ambulating well and moving well at this time.  The patient is passing gas, moving her bowels, urinating well, moderate lochia present, uterus is firm.  The patient is discharged from the hospital being given careful instructions to avoid douching, intercourse, strenuous activity, going up and down stairs, traveling by car.  She is to keep her incision clean with peroxide.  She was discharged with Darvocet-N 100 as needed for pain.  She will be followed up in 1 week for staple removal.  The patient was given information and instructions. Should she experience unusual bleeding, difficulty urinating, voiding, having a bowel movement or temperature elevation, she is to contact this physician.  Conversation with pediatric nurse indicated that there may be some concern of some chromosomal possibility here, with this baby, and chromosomal studies are being done to rule out Down’s.  Even though quad screen was negative, information is being awaited on this result.  The patient’s baby is also showing some jaundice and may be kept for another 24-48 hours to evaluate bilirubin levels.
 
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DATE OF ADMISSION:

DATE OF DISCHARGE: 

DISCHARGE DIAGNOSES:
1.  Term appropriate for gestational age infant.
2.  Formula intolerance.
3.  Impetigo in the ear.
4.  Mild jaundice.

HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE:  This baby was born to a gravida 6, para 1, preterm 0, abortus 4, living 1 (XX)-year-old mother.  EDC was MM/DD/YYYY.  The mother's blood type was A positive, rubella immune, nonreactive RPR, negative HIV, negative hepatitis, negative GC screen, triple screen was normal.  The baby's blood type was A positive.  All blood sugars checked on the baby were okay.  The child's birth measurements showed weight of 6 pounds 1.9 ounces or 2775 grams, length was 18-1/2 inches and head circumference was 34 cm.  The child did get the vitamin K injection and erythromycin to the eyes.  The baby also got the hepatitis B vaccine.  The child's weight at discharge was 5 pounds 15.6 ounces or 2710 grams.  While in the hospital, the baby was initially fed Enfamil liquid formula but was having some problems with spitting it up quite a bit.  On the day prior to discharge, it was switched to ProSobee and tolerated it much better.

The child on the initial physical examination had no abnormalities noted.  On discharge examination, the child looked very slightly jaundiced and had bilirubin checked.  Bilirubin was 6.6, so no treatment was needed.  The child also had an area of possible early impetigo developing on the right ear, at the margin, and we will be giving some Bactroban for that and will go home with the Bactroban to be continued t.i.d. at home.  The child will continue on the ProSobee as well.  The examination at discharge was unremarkable other than as noted above.  The child did have circumcision done and circumcision was done without difficulty, used EMLA cream and 1 mL of 1% lidocaine local anesthesia and 1.2 cm Plastibell and circumcision area looks good at discharge.   

    








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