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: Discharge Summary - Hip Surgery

Description: A 47-year-old female with a posttraumatic AV in the right femoral head.
(Medical Transcription Sample Report)

ADMITTING DIAGNOSIS: Posttraumatic AV in right femoral head.

DISCHARGE DIAGNOSIS: Posttraumatic AV in right femoral head.

SECONDARY DIAGNOSES PRIOR TO HOSPITALIZATION:
1. Opioid use.
2. Right hip surgery.
3. Appendectomy.
4. Gastroesophageal reflux disease.
5. Hepatitis diagnosed by liver biopsy.
6. Blood transfusion.
6. Smoker.
7. Trauma with multiple orthopedic procedures.
8. Hip arthroscopy.

POSTOP COMORBIDITIES: Postop acute blood loss anemia requiring transfusion and postop pain.

PROCEDURES DURING THIS HOSPITALIZATION: Right total hip arthroplasty and removal of hardware.

CONSULTS: Acute pain team consult.

DISPOSITION: Home.

HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: For details, please refer to clinic notes and OP notes. In brief, the patient is a 47-year-old female with a posttraumatic AV in the right femoral head. She came in consult with Dr. X who after reviewing the clinical and radiological findings recommended she undergo a right total hip arthroplasty and removal of old hardware. After being explained the risks, benefits, alternative options, and possible outcomes of surgery, she was agreeable and consented to proceed and therefore on the day of her admission, she was sent to the operating room where she underwent a right total hip arthroplasty and removal of hardware without any complications. She was then transferred to PACU for recovery and postop orthopedic floor for convalescence, physical therapy, and discharge planning. DVT prophylaxis was initiated with Lovenox. Postop pain was adequately managed with the aid of Acute Pain team. Postop acute blood loss anemia was treated with blood transfusions to an adequate level of hemoglobin. Physical therapy and occupational therapy were initiated and continued to work with her towards discharge clearance on the day of her discharge.

DISPOSITION: Home. On the day of her discharge, she was afebrile, vital signs were stable. She was in no acute distress. Her right hip incision was clean, dry, and intact. Extremity was warm and well perfused. Compartments were soft. Capillary refill less than two seconds. Distal pulses were present.

PREDISCHARGE LABORATORY FINDINGS: White count of 10.9, hemoglobin of 9.5, and BMP is pending.

DISCHARGE INSTRUCTIONS: Continue diet as before.

ACTIVITY: Weightbearing as tolerated in the right lower extremity as instructed. Do not lift, drive, move furniture, do strenuous activity for six weeks. Call Dr. X if there is increased temperature greater than 101.5, increased redness, swelling, drainage, increased pain that is not relieved by current pain regimen as per postop orthopedic discharge instruction sheet.

FOLLOW-UP APPOINTMENT: Follow up with Dr. X in two weeks.

Keywords: orthopedic, posttraumatic, femoral head, right hip surgery, transfusion, arthroplasty, removal of hardware, total hip arthroplasty, hip surgery, total hip, hip arthroplasty, removal, hardware, femoral, hip, discharge,
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