Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Orthopedic
Sample Name: Back & Leg Pain - Discharge Summary

Description: Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy. Chronic pain syndrome.
(Medical Transcription Sample Report)

ADMISSION DIAGNOSIS: Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.

SECONDARY DIAGNOSIS: Chronic pain syndrome.

PRINCIPAL PROCEDURE: L5 Gill procedure with interbody and posterolateral (360 degrees circumferential) arthrodesis using cages, bone graft, recombinant bone morphogenic protein, and pedicle fixation. This was performed by Dr. X on 01/08/08.

BRIEF HISTORY OF HOSPITAL COURSE: The patient is a man with a history of longstanding back, buttock, and bilateral leg pain. He was evaluated and found to have bilateral pars defects at L5-S1 with spondylolysis and instability. He was admitted and underwent an uncomplicated surgical procedure as noted above. In the postoperative period, he was up and ambulatory. He was taking p.o. fluids and diet well. He was afebrile. His wounds were healing well. Subsequently, the patient was discharged home.

DISCHARGE MEDICATIONS: Discharge medications included his usual preoperative pain medication as well as other medications.

FOLLOWUP: At this time, the patient will follow up with me in the office in six weeks' time. The patient understands discharge plans and is in agreement with the discharge plan. He will follow up as noted

Keywords: orthopedic, chronic pain syndrome, spinal instability, pars defects, radiculopathy, spondylolysis, leg,
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