Medical discharge summary report samples:
DISCHARGE SUMMARY REPORT #1
| RE: | Debra Jones |
| DATE: | 12/01/10 |
| MR: | 240804 |
| DOB: | 12/01/65 |
DIAGNOSES:
1. Cerebrovascular accident.
2. Schizophrenia.
3. Recurrent transient ischemic attacks.
PROCEDURES:
1. Echocardiogram.
2. Holter monitor.
HISTORY OF PRESENT ILLNESS:
This is a 59-year-old, right-handed woman with a history of hypertension, schizophrenia, and a fallopian ovarian tumor resection surgically and with radiotherapy treatment, who presented to the emergency room with a four-hour history of difficulty talking, and numbness and weakness on the right side. She was in her usual state of health until early the morning of admission when she woke up and noted numbness on her right side. Her numbness was associated with weakness as well as difficulty speaking, with no associated headache, chest pain, fever, chills, double vision difficulty swallowing, or palpitations. She reported having a similar incident about one month prior to admission when she was seen in the emergency room, but at that time, her symptoms resolve while in the emergency room. CT scan at that time showed bilateral basal ganglion infarcts. Carotid duplex then showed minimal plaque, rig ht greater than left, with no hemodynamic stenosis. At that time, she was sent home on aspirin 1 q.d. which she has been taking except for the day prior to admission when she missed her dose.
PHYSICAL EXAMINATIOS:
VITAL SIGNS: Temperature of 37.1, blood pressure of 164/100 in both arms.
HEENT: Clear.
NECK: Mild right bruit.
HEART: Regular rate and rhythm with no murmurs.
LUNGS: Clear.
ABDOMEN: Obese with a surgical scar. Bowel sounds were present.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: She is alert and oriented x 3. She had difficulty with speech, mostly lingual sounds. No aphasic symptoms. Normal flow, normal rate, and normal content. No breathlessness noted. Cranial nerves showed right fundi with sharp discs, pupils reactive 3 to 2 bilaterally, full extraocular movements and full visual fields. Corneal reflexes were present bilaterally. Decreased V1 through V3 pinprick on the face. Masticatory muscles were normal. Face was symmetric. Eye closure, puffed cheeks and smile were symmetric. Uvula and tongue were midline. Her gag was present bilaterally, left greater than right. Motor examination showed increased tone in the left arm. Strength was 4/4 in the right upper and lower extremities and 5/5 in the left upper and
lower extremities. Reflexes were 2+ throughout with downgoing toes. Sensory examination showed decreased pinprick on the right side. There was decreased vibration bilaterally in upper and lower extremities. Normal stereognosis and graphesthesia. Gait: She was able to bear weight on the left with some difficulty.
LABORATORY DATA:Unremarkable. Head CT scan at the time of admission showed bilateral lacunae of the anterior internal capsule with basal ganglion involvement; no change from prior CT scan. Electrocardiogram showed normal sinus rhythm at 81 with Q-waves in leads I and aVL, and small Q-waves in V1 and V6.
HOSPITAL COURSE: The patient was admitted to the neurology service with concern for an embolic versus ischemic event in the face of aspirin therapy. As an inpatient, she had an echocardiogram which was reported to show mild, concentric, left ventricular hypertrophy with normal left ventricular function, no segmental wall abnormalities, no mitral regurgitation, no aortic regurgitation and no tricuspid regurgitation. No evidence of coral thrombus. Carotids were not repeated, since she had a carotid study one month prior to admission that showed an occlusion of her carotids. RPR was nonreactive. Blood pressure remained under control during hospitalization. Her psychiatric symptoms were stable during this time. She was seen by physical therapy and occupational therapy who helped her with ambulation, and by discharge she was making good progress, ambulating and using her arms, although she remained with weakness on the right more marked than the left. She was discharged in good health.
DISCHARGE MEDICATIONS:
1. Nortriptyline 25 mg p.o. q.h.s.
2. Benadryl 50 mg p.o. q.h.s.
1. Navane 5 mg p.o. q.h.s
2. Aspirin two p.o. b.i.d.
DISCHARGE INSTRUCTIONS:
1. Diet: Low-cholesterol, low-fat diet.
2. Activity: As tolerated.
FOLLOW-UP CARE:
1. Follow up with physical therapy and occupational therapy.
2. Return to the neurology clinic about one month after discharge.
DISCHARGE SUMMARY REPORT #2
| DATE OF ADMISSION: | 07/25/10 |
| DATE OF DISCHARGE: | 07/25/10 |
ADMITTING DIAGNOSIS:Torn medial meniscus of left knee.
HOSPITAL COURSE: This 52-year-old male with a work related injury to his left knee and failure to improve on conservative therapy with MRI scan indicating oblique tearing of the posterior horn of the medial meniscus of the left knee was admitted at this time for diagnostic operative arthroscopic surgery. The patient underwent routine preadmission testing and was cleared for surgery. He was taken to the Operating Room on the date of admission and, under general anesthesia underwent resection of a torn posterior horn of his medial meniscus with chondroplasty of the anterior surface of the medial femoral condyle for grade III chondromalacia and three compartmental synovectomy for hypertrophic synovitis. Autogenous platelet gel fabricated from the patient’s own blood preoperatively was utilized to facilitate soft tissue healing.
DISPOSITION: The patient tolerated the surgical procedure well. Upon recovering from his anesthesia, he was allowed to ambulate with a bulky Jones dressing and extension knee brace.
CONDITION ON DISCHARGE: He was discharged home ambulating with crutches and weight bearing as tolerated.
FOLLOW-UP: The patient was discharged with instructions to return to see me in my office in 24 hours time for dressing removal and wound follow up care.
DISCHARGE MEDICATIONS: The patient was discharged home taking Darvocet-N 100 for pain and Omnicef 300 mg one tablet twice daily as a prophylaxis against infection.
OUTPATIENT SUMMARY REPORT SAMPLE #3
| DATE OF SURGERY: | 07/25/10 |
| DATE OF DISCHARGE: | 07/25/10 |
REASON FOR ADMISSION: This is a 36-year-old female who was admitted to the hospital as an outpatient for D&C because the patient had been having irregular vaginal bleeding between her menstruations.
HISTORY: By history, she underwent in 2006 a previous D&C for the same reason.
PHYSICAL EXAMINATION: Heart and lungs are within normal limits. Breasts: No masses, somewhat enlarged. The uterus was somewhat enlarged.
ALLERGIES: The patient denies any drug allergies.
SURGICAL HISTORY: The patient has a history of tubal sterilization and tubal ligation.
At the time of this examination the patient provided normal pregnancy test that was negative.
HOSPITAL COURSE: On admission a D&C carried out with no complications.
DISCHARGE INSTRUCTIONS: The patient was discharged the day of the procedure to be seen in the office within a week.
OPERATION: D&C.
FINAL DIAGNOSIS: Menometrorrhagia.