Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Discharge Summary

A clinical report prepared by a physician or other health professional at the conclusion of a hospital stay or series of treatments. It outlines the patient's chief complaint, the diagnostic findings, the therapy administered and the patient's response to it, and recommendations on discharge.



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Lap Chole - Discharge Summary
Laparoscopic cholecystectomy. Acute cholecystitis, status post laparoscopic cholecystectomy, end-stage renal disease on hemodialysis, hyperlipidemia, hypertension, congestive heart failure, skin lymphoma 5 years ago, and hypothyroidism.

Laryngitis - Discharge
Chronic laryngitis, hoarseness. The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.

Leiomyosarcoma
Discharge summary of patient with leiomyosarcoma and history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia.

Mastoiditis - Discharge Summary
Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.

Mullerian Adenosarcoma
Discharge summary of a patient presenting with a large mass aborted through the cervix.

Multiple Medical Problems - Discharge Summary
Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, and congestive heart failure.

Neck Pain - Discharge Summary
Neck pain with right upper extremity radiculopathy and cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.

Neonatal Discharge Summary
The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation. Mother had two previous C-sections.

Neonatal Discharge Summary - 1
Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity. The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.

Neurology - Discharge Summary
Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.

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NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples