DATE OF DISCHARGE: MM/DD/YYYY

DISCHARGE DIAGNOSES:
1.  Anterior ischemic optic neuropathy.
2.  Left cavernous internal carotid artery aneurysm and left anterior coronary artery aneurysm.

CONSULTATIONS:  Ophthalmology.

PROCEDURES:
1.  MRI of the brain with and without contrast and diffusion as well as MRI of the orbits with and without contrast.
2.  MRA of the head and neck.
3.  Transthoracic echocardiogram with bubble study.
4.  Four-vessel cerebral angiogram.
5.  CT without contrast of the abdomen and pelvis.

HOSPITAL COURSE:  This is a (XX)-year-old female who presented with a chief complaint of decreased visual acuity for one week. The patient reportedly saw a neurologist who did an MRA of the brain and LP. By verbal report, the MRI showed white matter disease, and the results of the LP were unknown at the time the patient was initially evaluated.

The patient was also started on Plavix by Dr. John Doe at that time. The patient was noted to have an inferior altitudinal field defect in her left eye as well as a scotoma. The remainder of the patient’s exam was essentially normal. However, the patient gave report that she has a significant family history with a brother, who presented very similarly with acute visual loss. They suspected that the patient may have had an embolic event or an anterior ischemic optic neuropathy.

Subsequently, the patient had an MRI of the brain and orbit and MRA of the head and neck for evaluation. In addition, she had a transthoracic echocardiogram to rule out possible cardioembolic stroke. The patient was also asked to be seen by Ophthalmology to rule out other etiologies of acute visual loss. The patient was also started on aspirin in addition to the Plavix the patient was already on.

In addition, the patient had genetic tests to rule out possible mitochondrial disorder (Leber optic neuropathy). The patient revealed scattered punctate T2 abnormalities in the periventricular subcortical white matter area, which is nonspecific for small vessel disease versus demyelinating. There are no abnormalities noted at the optic nerve. The MRA of the head and neck, however, did show two small atherosclerotic aneurysms in the cavernous segment of left internal carotid artery, while the transthoracic echocardiogram was negative for any valid pathology with a negative bubble study.

Due to the presence of possible aneurysm on the MRA, we suspect this may be possible source of embolisms. It was decided that cerebral angiogram would be done for better characterization of the vasculature. The cerebral angiogram once again revealed a 4 mm left cavernous internal carotid aneurysm as well as a smaller 1-2 mm left anterior coronary artery aneurysm, both without evidence of clots.

Ophthalmology, as previously noted, was asked to see the patient for further evaluation, and they also felt that patient’s visual loss was secondary to anterior ischemic optic neuropathy and were agreeable for an embolic workup as well as vasculitic workup. As noted, the cerebral angiogram did not show any evidence of any vasculitic process and the patient had a normal sed rate. They too were also agreeable to the use of antiplatelet agent unless an embolic source was found or requiring patient to require anticoagulation.

Based on the patient’s studies, it was decided that the patient should be placed on double antiplatelet therapy, namely Plavix and aspirin, as she was started on admission. The patient’s hospital course was generally uncomplicated with the exception of an episode following the cerebral angiogram where the patient was hypotensive with a blood pressure of 86/40 at which time the patient was symptomatic, feeling nauseous and cold and clammy. The patient’s blood pressure responded to fluids, and the patient remained hemodynamically stable with an H&H of 12.8 and 37.8 respectively.

However, with the patient’s recent cerebral angiogram, there was concern that during the patient’s episode of hypotension, she may have had retroperitoneal bleed. Subsequently, abdominal and pelvic CT without contrast was done to rule out hematoma; although, it was somewhat limited but asked not to receive any contrast. There was no evidence for retroperitoneal hemorrhage. In fact, the patient had no further episodes of hypotension the remainder of her hospitalization.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Stable. Afebrile.
GENERAL:  The patient is awake, alert, and oriented x4.
NEURO/OPTICAL EXAM:  Cranial Nerves: Pupils are reactive on the right with an afferent defect on the left. Left inferior field cut on confrontational testing. Funduscopic exam was well visualized. Extraocular muscles are intact. Face is symmetric. Tongue is midline.
LUNGS:  Clear to auscultation bilaterally.
HEART:  Regular rate and rhythm without murmurs, rubs or gallops.
RECTAL:  Deferred.
BACK:  Specifically nontender.
EXTREMITIES:  Motor is 5/5 in the upper and lower extremities bilaterally.
NEUROLOGICAL:  Sensation is grossly intact to light touch and proprioception. DTRs are 2+ and symmetric throughout. Toes are downgoing bilaterally. Gait is normal. Cerebellar function intact on finger-to-nose and rapid alternating movement.

DISCHARGE MEDICATIONS:  Plavix 75 mg p.o. daily and aspirin 81 mg p.o. daily.

DISCHARGE CONDITION:  The patient was discharged in stable condition.

DISCHARGE INSTRUCTIONS:  The patient is to follow up with Dr. John Doe. It was recommended that the patient have a followup MRA to evaluate her aneurysms in approximately six months for any further change. Because of the size of the patient’s aneurysm, it was discussed with the patient and her husband, more than likely the patient would not require any neurosurgical intervention at this time unless there has been a change in the size of the aneurysm. The patient is to follow up with Ophthalmology.

The post Anterior Ischemic Optic Neuropathy Discharge Summary Sample appeared first on Medical Transcription Sample Reports.

DATE OF ADMISSION: MM/DD/YYYY

DATE OF DISCHARGE: MM/DD/YYYY

DISCHARGE DIAGNOSES:
1.  Seizure disorder.
2.  History of traumatic brain injury.
3.  History of bipolar disorder.

DISCHARGE MEDICATIONS:
1.  Aspirin 325 mg by mouth daily.
2.  Dilantin 200 mg by mouth twice a day.
3.  Depakote 500 mg in the morning, 250 with dinner, and 500 at night.
4.  Clozaril 325 mg by mouth at night.
5.  Desmopressin 0.1 mg by mouth at night.
6.  The patient is to resume all prior skin care and as-needed medications.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male admitted through the emergency department with seizure activity. It is unclear whether this patient actually has a history of a seizure disorder or not. Both he and his family deny history of seizure disorder; although, it is documented on the nursing home paperwork that he does have a seizure disorder, so it is not clear. In any event, the patient was admitted to the ICU as he did require intubation secondary to the seizure activity.

HOSPITAL COURSE:
1. Seizure disorder. Again, not clear if this is new onset or not. He had a lumbar puncture and an MRI, extensive evaluation, and was seen by Dr. John Doe of neurology, and it was felt that the likely indwelling source for the seizure is the history of traumatic brain injury. There were no structural deficits noted and no evidence of focal epileptiform activity on EEG. He was loaded with Dilantin, and he has had no further seizure activity since.
2. Respiratory failure. The patient was actually intubated more for airway protection and was presumed with respiratory failure secondary to the seizure activity and the sedation necessary to stop the seizure activity. He was easily extubated and had no further respiratory issues.
3. History of bipolar disorder. He continues on his Depakote and Clozaril.
4. Dysphagia. There was some concern about the possibility of aspiration. He had a swallow evaluation and modified barium swallow, which recommended mechanical soft diet with nectar-thick liquids, pureed meats, and no bread. He is doing well. At the time of discharge, he is awake, alert, and oriented. The patient denies any complaints and is tolerating the currently recommended diet without any difficulty. He is being discharged.

The post Seizure Disorder Discharge Summary Sample Report appeared first on Medical Transcription Sample Reports.

DATE OF ADMISSION: MM/DD/YYYY

DATE OF DISCHARGE: MM/DD/YYYY

ADMITTING PHYSICIAN: John Doe, MD

ADMISSION DIAGNOSES:
1. Longstanding gastroesophageal reflux.
2. Esophagitis.

DISCHARGE DIAGNOSES:
1. Longstanding gastroesophageal reflux.
2. Esophagitis.

OPERATION PERFORMED: Laparoscopic Nissen fundoplication.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female in general good health, who presents now with a 9-year history of requiring medication and treatment for gastroesophageal reflux disease. She had progressed through various anti-H2 and proton pump inhibitor agents and was dependent upon them for symptom relief. She was requiring increasing doses of those medications for relief. She did have an EGD, which documented presence of esophagitis and early changes of columnar epithelium but no evidence of metaplasia or malignancy. She was found to have hiatal hernia with reflux on preoperative testing. On the basis of her prolonged symptoms and need for medication and documented pathology, surgical intervention was offered and undertaken.

ADMISSION PHYSICAL EXAMINATION: Remarkable for abdomen, which is soft, flat and nontender. Bowel sounds are normal. No abnormal masses or hepatosplenomegaly. No umbilical or groin bulges. She had some laparoscopic scars from previous laparoscopic cholecystectomy and appendectomy.

ADMISSION LABORATORY DATA: Overall, unremarkable.

HOSPITAL COURSE: The patient was admitted and on the day of admission was taken to the main operating room. Under general anesthesia, she had a diagnostic laparoscopy with laparoscopic Nissen fundoplication. She was found to have moderate-sized hiatal hernia, which was repaired. She was noted to have healing of the previous operative sites in the subhepatic space and in the right lower quadrant. There was no evidence of other significant pathology. The patient tolerated the procedure well and recovered without incident.

DISPOSITION: Home.

DISCHARGE CONDITION: The patient is ambulating and tolerating p.o. without emesis with only mild discomfort. She has been afebrile with stable vital signs since surgery. Her abdomen was soft and nontender. Her wounds are healing with no erythema or drainage.

DISCHARGE INSTRUCTIONS: Diet: Regular and mechanical soft. Activity: Ad lib.

MEDICATIONS: Percocet 1-2 p.o. q. 4-6 hours p.r.n. pain.

FOLLOWUP: The patient is to follow up with us routinely in three weeks. She will call sooner for severe pain, wound redness or drainage, temperature of 101 degrees Fahrenheit, persistent emesis or diarrhea.

The post Gastroesophageal Reflux Discharge Summary Sample Report appeared first on Medical Transcription Sample Reports.

DATE OF ADMISSION: MM/DD/YYYY

DATE OF DISCHARGE: MM/DD/YYYY

CHIEF COMPLAINT: Abdominal pain.

HISTORY OF PRESENT ILLNESS: This (XX)-year-old Hispanic male had rapid onset of severe epigastric pain earlier on the day of admission. This was not affected by position. It was somewhat worse with movement and respiration. It was associated with mild nausea. He had no vomiting, diarrhea, melena or hematochezia. He was brought to the emergency department via ambulance. CT scan was done urgently to rule out dissecting aortic aneurysm. It was unremarkable, except for evidence of pancreatitis. He had a serum amylase of 3320 and lipase of 15,060. His peripheral white cell count was 17,400. Bilirubin, alkaline phosphatase, AST, and ALT were normal. See admission history and physical for details.

HOSPITAL COURSE: Gastroenterology consult was obtained. The patient was kept n.p.o. and given parenteral analgesics. His serum amylase and lipase gradually improved. He developed fever. Infectious disease consult was obtained. He was given intravenous Merrem from hospital day #6 through the date of discharge. Abdominal ultrasound showed increased liver size and echogenicity, likely representing fatty liver. The gallbladder was normal. The pancreas could not be well visualized due to the patient’s body habitus and large quantity of overlying bowel gas. The patient continued to have abdominal pain. This was exacerbated by any attempt at taking oral nutrition.

Repeat CT scan of the abdomen on hospital day #5 again showed diffuse pancreatic enlargement, infiltration, and stranding of the anterior pararenal space consistent with pancreatitis. The second CT scan actually appeared to be a little worse than the initial scan. He had progressive pulmonary infiltrates. MRI of the abdomen showed no abnormality other than those consistent with pancreatitis. The patient received peripheral hyperalimentation from hospital day #6 until his discharge. His symptoms eventually subsided somewhat. He was able to take clear liquids but continued to have pain. Eventually, this was controlled with oral analgesics.

DISPOSITION: The patient was discharged home.

DISCHARGE INSTRUCTIONS: He was given instructions on a clear liquid diet. He is to completely abstain from consuming alcohol.

DISCHARGE MEDICATIONS: He was given a prescription for Percocet 5/325 mg 2 tablets p.o. q. 4 h. p.r.n. pain. He was instructed to continue his preadmission medications of Lotrel 5/20 mg daily, Prevacid 30 mg daily, Zocor 80 mg daily, and Finacea cream daily. He is to see Dr. John Doe two weeks after discharge and us one month after discharge.

FINAL DIAGNOSES:
1.  Acute pancreatitis.
2.  Hypertension.
3.  Hyperlipidemia.
4.  Atherosclerotic cardiovascular disease.
5.  Rosacea.

The post Acute Pancreatitis Discharge Summary Sample Report appeared first on Medical Transcription Sample Reports.

DATE OF ADMISSION: MM/DD/YYYY

DATE OF DISCHARGE: MM/DD/YYYY

DIAGNOSES:
1.  Shortness of breath.
2.  Aortic valve disorder.
3.  Hypertension.
4.  Malignancy of the prostate.
5.  Diabetes.

HISTORY OF PRESENT ILLNESS:  The patient is a pleasant (XX)-year-old male patient who is well known to us, diagnosed with a prostate carcinoma. He also has history of diabetes, no past history of coronary artery disease, presented to the emergency department with shortness of breath and lower extremity edema. He is denying chest pain. He was treated in the ER and then admitted for further evaluation and treatment.

HOSPITAL COURSE:  Upon admission, the patient was placed on IV fluids. Labs were obtained. Chest x-ray was ordered. Consult was made to the cardiologist, and the patient was ordered to a monitored bed. The patient was seen in a consultation by Dr. John Doe. After his assessment, impression was dyspnea, metastatic prostate cancer, hypertension, and diabetes. The plan was to rule out myocardial infarction with serial cardiac enzymes and ECG. Continue medical therapy and aspirin daily. Check echocardiogram. Start the patient on Zestril. Give Lasix for edema. Check basic metabolic panel. Check CT scan of the chest to evaluate for metastatic disease or pulmonary embolism. Medical management from cardiac standpoint.

CT of the chest revealed no evidence of major central pulmonary emboli, interstitial pattern, particularly prominent at the bases, which could be chronic with a mild hazy pattern at both bases. Could be active interstitial process superimposed upon chronic interstitial lung disease. No consolidation, no pneumothorax, no pleural effusion. Vascular calcification of the aorta and branching vessels, particularly of coronary arteries, multiple. Cardiac enzymes were normal. A bone scan obtained revealed multiple metastatic lesions as described, both kidneys functioning, no hydronephrosis noted. The patient responded well to medical management.

Case management was consulted with regard to discharge planning. The patient, at this time, is living with his ex-girlfriend. Placement was requested. Once arrangements were made, the patient was then discharged to the extended care facility.

The post Shortness of Breath Discharge Summary Sample appeared first on Medical Transcription Sample Reports.

DATE OF DISCHARGE:  MM/DD/YYYY

ATTENDING PHYSICIAN:  John Doe, MD

DISCHARGING PHYSICIAN:  Jane Doe, MD

FINAL DIAGNOSES:
1.  End-stage cardiomyopathy.
2.  Cirrhosis of the liver with ascites.
3.  History of polysubstance abuse disorder.
4.  Noncompliance to medication treatment.

DISCHARGE MEDICATIONS:  Bumex 1 mg p.o. twice daily, lisinopril 2.5 mg once daily, carvedilol 3.125 mg twice daily, digoxin 0.25 mg once daily, aspirin 325 mg once daily, spironolactone 25 mg once daily, morphine sulfate immediate release 10 mg p.o. every 4 hours p.r.n. pain, potassium chloride extended release 1 tablet p.o. p.r.n. and Tylenol 650 mg p.o. every 4 hours p.r.n. pain.

FOLLOWUP INSTRUCTIONS:  The patient should be discharged to inpatient hospice, and he should have follow up with inpatient hospice for further management of his end-of-life care and end-stage cardiomyopathy care.

HOSPITAL COURSE:  This unfortunate gentleman with history of end-stage cardiomyopathy with last ejection fraction of 15% was admitted with shortness of breath and severe edema. He also has a diagnosis of cirrhosis of the liver with ascites. The patient was seen by Cardiology, who recommended hospice care. His diuretic medications were optimized, and he was placed on Coreg.

The patient does have a very poor left ventricular function and has low blood pressure, which precludes aggressive diuretic management. However, the patient seems to be doing fairly well with his current regimen. He did have a paracentesis for therapeutic purposes with 1600 mL of fluid removed from his peritoneum. He tolerated the procedure well and albumin has been replaced prior to discharge.

The patient does have an artificially implanted cardioverter-defibrillator, which will be continued. The patient is being discharged back to the care for inpatient hospice, which he has agreed to.

Pertinent laboratory studies during this hospital course showed the following results. White cell count was 3.8, hemoglobin 10.4, platelet count 162,000. INR 1.62, prothrombin time 19.4. Sodium 130, potassium 4.2, creatinine 0.9. Total bilirubin 4.9, alkaline phosphatase 82, ALT 36, and AST 54.

DISPOSITION:  Plan is for inpatient hospice.

The post End-Stage Cardiomyopathy Discharge Summary Sample Report appeared first on Medical Transcription Sample Reports.

DATE OF DISCHARGE:  MM/DD/YYYY

BRIEF HISTORY AND HOSPITAL COURSE:  The patient is a (XX)-year-old Asian female with rectal cancer metastatic to lymph nodes, liver, and lung. She had recent progression of disease, despite chemotherapy with Erbitux and Camptosar.

We admitted the patient with fever. This developed 10 days prior to admission. She had been started on Tamiflu at an outside clinic, yet did not improve on this therapy. She subsequently had blood cultures in our office, which were negative. After 10 days of failure to improve as an outpatient, we arranged this admission.

At the time of admission, we arranged blood cultures, which were unrevealing. Urinalysis and urine culture was negative at the time of this dictation. To rule out an intra-abdominal area of infection, we obtained a CT scan of the abdomen and pelvis. This showed progression of metastatic disease in the liver.

Two large metastatic lesions had fused into a single 10 x 10 cm metastasis in the right lobe. A mass near the porta hepatis measured 2.5 cm. There were enlarged retroperitoneal lymph nodes. The lower lung fields showed an area of infiltrate and atelectasis at the right lung base, new since the previous examination. This area of her abnormality was not visible on the chest x-ray. The patient had rales audible in this area.

We initially started a combination of cefepime and metronidazole and stopped metronidazole when we found no infection within the abdomen. The patient rapidly improved. Her temperature rose to 100.6 degrees Fahrenheit on the day following admission, then remained normal the final 36 hours of her hospital stay.

At that point, we changed antibiotic therapy to Ceftin 250 mg p.o. b.i.d. and allowed her to return home. The patient will also have Compazine 10 mg q.i.d. for nausea. She had relief of nausea with Zofran but could not afford this medication.

The patient will return to our office for followup of her metastatic rectal cancer. We suspect we will be unable to control that malignancy; although, we may attempt therapy with medications such as Xeloda. Unfortunately, the patient’s long-term prognosis is quite poor.

FINAL DIAGNOSES:
1.  Fever, probably due to pneumonia.
2.  Rectal cancer with extensive metastases.

The post Fever Probably Due to Pneumonia Discharge Summary Sample appeared first on Medical Transcription Sample Reports.

DATE OF DISCHARGE:  MM/DD/YYYY

ADMISSION DIAGNOSIS:  C3 through C7 spondylosis with myelopathy.

DISCHARGE DIAGNOSIS:  C3 through C7 spondylosis with myelopathy.

PROCEDURE PERFORMED:  Stage I C3 through C7 anterior cervical discectomy and fusion with plating. Planned stage II C3 through C7 redo decompression posterior fusion.

HOSPITAL COURSE:  The patient is a (XX)-year-old male admitted with the above diagnosis. The patient was taken to the operating room first on MM/DD/YYYY and then on MM/DD/YYYY to undergo the above-stated surgical procedures. The patient tolerated these procedures well and postoperatively was extubated and taken to the recovery room in stable condition.

Once in the recovery room, the patient continued to do well. He became more awake and alert and soon was moving all extremities. The patient had no difficulty swallowing or with respirations. He was slightly hoarse but was afebrile with stable vital signs and moving all extremities well. The patient was then transferred to the neurologic intensive care unit where he remained in stable condition.

Neurologically, the patient remained stable. His Hemovac drain, Foley catheter, and PCA pump were eventually discontinued. His anterior and posterior incisions remained clean and dry and dressing was intact. The patient was seen by Physical and Occupational Therapy. The patient denied radicular pain, numbness or tingling. The patient continued to mobilize with physical therapy assistance. The patient did have some pre-existing right-sided weakness, which persisted after surgery. He was walking with a walker and continued to progress with this. The patient was seen by Respiratory Therapy for rhonchi and wheezing in his chest. The patient was also seen by the medical service for this. The patient had no neurologic complaints and continued to progress.

He was soon evaluated and found to be fit for discharge to an inpatient rehab facility. Once medically stable, the patient was cleared for transfer and was discharged in stable condition with family and the appropriate followup appointment scheduled. During his stay, the patient also received IV antibiotics through a peripherally inserted central catheter.

DISCHARGE CONDITION:  Stable.

DISPOSITION:  Inpatient rehabilitation facility.

DISCHARGE INSTRUCTIONS:  The patient will follow up in the office in two to three weeks. Wound care, activity, and other instructions as well as pain medication prescriptions have been given for discharge. The patient and his family understand that they are to call the office in the interim if any problems or questions prior to followup visit arise.

The post Spondylosis with Myelopathy Discharge Summary Sample appeared first on Medical Transcription Sample Reports.

DATE OF DISCHARGE: MM/DD/YYYY

DIAGNOSES:
1. Gastrointestinal hemorrhage.
2. Blood loss anemia.
3. Gastric ulcer and gastritis and duodenitis.
4. Hypertension.
5. Renal failure.
6. Diabetes mellitus.
7. Hydronephrosis.
8. Hyperlipidemia.
9. Multiple strokes.

PROCEDURES: Esophagogastroduodenoscopy with biopsies.

CHIEF COMPLAINT: Vomiting blood.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old woman, previously admitted for melena in the past on two occasions, had EGD done on both occasions with history of ulcers and has also some history of diabetes and hypertension and renal insufficiency, who has not been compliant with followup for at least one year and taking any medications.

The patient came to the emergency room because of a history of six episodes of watery bloody diarrhea of cranberry juice color, hematemesis, and then came to the emergency room. She had been taking apparently some Advil for various aches and pains, particularly in the shoulders, for the past two years, at a rate of at least 400 mg twice a day. She denies any lightheadedness, dizziness, syncope, anorexia, weight loss, nausea, abdominal pain, hematuria or dysuria. She does feel a little short of breath, and she had some chest pains two days prior to admission. When she was seen in the emergency room, the NG tube was placed, and she was found to have 1 liter of burgundy fluid and was immediately given infusions of O type blood, 3 units of packed red blood cells, at which time her hemoglobin was approximately 6. The patient was transferred to the intensive care unit for further evaluation and treatment.

PAST MEDICAL HISTORY: Includes a history of diabetes mellitus, hypertension, hyperlipidemia, melena, acute renal failure, and TIA. For the melena, she has had EGD done twice with bleeding ulcers.

ALLERGIES: No known allergies.

MEDICATIONS: Her only medication currently is Advil.

SOCIAL HISTORY: The patient lives with a significant other. The patient has quit smoking, and there is no known alcohol use.

PHYSICAL EXAMINATION:
GENERAL: The patient is a pleasant, alert, middle-aged woman in no acute distress.
VITAL SIGNS: Temperature 96.4, pulse 100, respiratory rate 28, blood pressure 138/40, and 99% O2 saturation on oxygen.
HEENT: Normal.
NECK: Supple. No JVD.
LUNGS: Clear.
HEART: Regular rhythm and rate.
ABDOMEN: Nontender.
RECTAL: No masses but has gross blood present.
EXTREMITIES: No edema or cyanosis.
NEUROLOGIC: Within normal limits.

DIAGNOSTIC DATA: Followup hemoglobin is 8.9 and 26.2 with the initial one being about 6. The white blood cell count is, however, 29,600. Chest x-ray shows no infiltrates. Initial potassium was 6.5 and decreased to 5.2 with a bicarbonate of 9 and a BUN of 58, creatinine of 2.5, glucose of 162. Liver function tests are slightly abnormal with AST of 96 and ALT of 40. Total bilirubin is 0.8.

HOSPITAL COURSE AND TREATMENT: The patient was admitted to the intensive care unit where she was given sodium bicarbonate to correct the acidosis. She was given insulin and D50 and calcium gluconate for the hyperkalemia. She was given IV Protonix, and GI consultation was obtained. She was monitored with respect to her glucoses and her blood pressure.

The patient was given additional packed red blood cells and FFP, and EGD was performed showing the presence of the gastritis and gastric ulcers and duodenitis, and she was observed in the intensive care unit for several days. She had only 10,000 colonies on the urine culture, so she had been started on ciprofloxacin, but this was discontinued. The patient had been given metoprolol and nitroglycerin paste for the hypertension that she had. At the time that she left the intensive care unit, her hemoglobin was 9.6 and electrolytes were normal and her BUN was 50 and creatinine was 1.6.

The patient was then transferred to the monitored floor. She was continued on IV Protonix and continued on the same antihypertensives and observed. She was switched over to Norvasc 10 mg, lisinopril 20 mg, and Toprol-XL 100 mg for blood pressure control. Her A1c was checked. The lipids were checked. The patient’s white blood cell count was 4800. Her BUN has decreased to 24 and creatinine was 1.2. Glucoses were approximately 140. She was negative for Helicobacter pylori on her biopsies.

The patient did complain of some possible neurologic deficits on the right side, mostly incoordination in the right upper and right lower extremities and some paresthesias. A CT discovered that she had some strokes of undetermined age, mostly the several low attenuation foci within the basal ganglia, left corona radiata, and left thalamus. These were probably lacunar infarcts; they were of undetermined age. The patient could, however, walk but she had poor coordination with her right hand.

The patient was seen to be stable on the Norvasc, lisinopril, Toprol for her blood pressure, and her glucoses were quite stable as well on insulin, and her activities were increased. She was stabilized and then she was discharged to home to continue on these various medications and will be followed up in a few days with Dr. John Doe. She is to be on a regular diet, no concentrated sweets, and activities are as tolerated.

The post Gastrointestinal Hemorrhage Discharge Summary Sample appeared first on Medical Transcription Sample Reports.

DATE OF DISCHARGE:  MM/DD/YYYY

HISTORY OF PRESENT ILLNESS:  This (XX)-year-old girl with sickle cell anemia was admitted because of marked direct hyperbilirubinemia and elevated liver enzymes. She had been admitted briefly in late February and then for several days in early March. On one admission, she had relatively modest elevation of liver enzymes but was improving. She was transfused the first week of March because of dropping hemoglobin and hematocrit. She complained of severe headaches and malaise. She was seen by her pediatrician on about the middle of March with signs and symptoms of sinusitis. She was prescribed Omnicef.

A week to 10 days later, Dr. John Doe called us to discuss the patient. The child had severe generalized itching rash consistent with drug rash. It was agreed to stop Omnicef and give her a brief course of Orapred 1 mg/kg/day to alleviate the rash. He re-examined the child the next day to be sure she was not worse. The child’s mother called Dr. John Doe the morning of admission and described the child as much more jaundiced and seeming weak and complaining of abdominal pain. Dr. John Doe instructed her to bring the child for evaluation and probable admission.

MEDICATIONS:  Other medications in addition to prednisone were Pepcid 10 mg two times a day, Zyrtec at bedtime, and folic acid 1 mg daily.

PHYSICAL EXAMINATION:  GENERAL: On arrival, the child was obviously markedly icteric with sclerae and palate very yellow. VITAL SIGNS: Temperature 99.8 degrees, heart rate 112, respiratory rate 22, blood pressure 122/84, weight 23.8 kilograms, and oxygen saturation 92% on room air. ABDOMEN: In addition to jaundice and protuberant and distended abdomen, which was soft with definite hepatomegaly, her liver edge was felt at least 7 cm below the right costal margin. The rest of the physical examination was not particularly remarkable.

LABORATORY DATA:  Quite significant. Total bilirubin was 20.8, direct was greater than 10. Albumin was 4.8, total protein 8.6, alkaline phosphatase 450, SGOT 1022, and SGPT 774. Amylase and lipase were normal. Basic metabolic profile was unremarkable. The urine showed large bilirubin. CBC showed white blood cell count of 12,500, hemoglobin 8.4, hematocrit 24, and platelet count 526,000, 70 segs, 5 bands, 22 lymphs, 3 monos, 26 nucleated red blood cells per 100 white cells and a reticulocyte cell count of 14.2%.

HOSPITAL COURSE:  It was noted that she had had an abdominal ultrasound in February that showed no gallstones and no gallbladder abnormality. It seemed very unlikely that this was a biliary obstruction and more likely that it was intrahepatic sickling. Pediatric gastroenterology consult was sought. They suggested getting an immediate abdominal ultrasound and planned for the followup.

By the morning after admission, she felt somewhat better and was no longer complaining of abdominal pain. She had no fever and said she was hungry. Total bilirubin was 4.8, direct 2.4, SGOT 320, SGPT 520, alkaline phosphatase 400. PT 15.6, PTT 29.2, and fibrinogen 272. Hepatomegaly was about 7 cm. No enlarged spleen was felt. She looked a little less jaundiced but was still definitely icteric, and it was noted that with minimal intervention, that was just hydration overnight, bilirubin had improved remarkably. The abdominal ultrasound showed no specific abnormality.

The pediatric gastroenterologist saw her and her ultrasound and felt that this finding of the sudden jaundice with the rash was most consistent with an adverse drug reaction to the Omnicef that she had received. Omnicef can cause cholestatic jaundice. She developed an itching rash on her legs, again in the hospital, and had an episode of sweating. She was given Benadryl for the itching. There was a concern that this could be a flare-up of the drug rash. She was observed to see if the rash was stable or getting worse.

Two days before discharge, there was concern that the rash was worse. She was observed carefully. On the day before discharge, she had a low-grade fever. She was continued on hydration. She was watched off any antipyretics with a plan if she developed fever above 101, to obtain blood cultures and then start clindamycin. Fortunately, she did not spike fever but indeed became afebrile. Total bilirubin went down to 3.3 with a direct of 1.6, SGOT 90, and SGPT 40. It was noted that serum IgG was 1276, IgM 154, and IgA 254. Since she had resolved almost all of her problems by the date of discharge, she was discharged to home.

DISCHARGE DIAGNOSES:
1.  Cholestatic jaundice, probably caused by an adverse reaction to Omnicef.
2.  Sickle cell anemia.
3.  Allergic rash to Omnicef.

The patient had an abdominal ultrasound and red cell transfusion during her admission. As noted before, at the time of admission, her total bilirubin was 20.8 with markedly elevated SGOT and SGPT. During her admission, additional tests were sent. An acute hepatitis panel was negative for any evidence of active hepatitis B, hepatitis A, or hepatitis C. Coagulation studies, as noted, were not particularly remarkable. Bilirubin did resolve.

The post Cholestatic Jaundice Discharge Summary Sample Report appeared first on Medical Transcription Sample Reports.