Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
|

View this sample in Blog format on MedicalTranscriptionSamples.com

Sample Type / Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 5

Description: A female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity.
(Medical Transcription Sample Report)

DATE OF ADMISSION: MM/DD/YYYY.

DATE OF DISCHARGE: MM/DD/YYYY.

REFERRING PHYSICIAN: AB CD, M.D.

ATTENDING PHYSICIAN AT DISCHARGE: X Y, M.D.

ADMITTING DIAGNOSES:
1. Ewing sarcoma.
2. Anemia.
3. Hypertension.
4. Hyperkalemia.

PROCEDURES DURING HOSPITALIZATION: Cycle seven Ifosfamide, mesna, and VP-16 chemotherapy.

HISTORY OF PRESENT ILLNESS: Ms. XXX is a pleasant 37-year-old African-American female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity. She presented initially with a left frontal orbital swelling to Dr. XYZ on MM/DD/YYYY. A biopsy revealed small round cells and repeat biopsy on MM/DD/YYYY also showed round cells consistent with Ewing sarcoma, genetic analysis indicated a T1122 translocation. MRI on MM/DD/YYYY showed a 4 cm soft tissue mass without bony destruction. CT showed similar result. The patient received her first cycle of chemotherapy on MM/DD/YYYY. On MM/DD/YYYY, she was admitted to the ED with nausea and vomitting and was admitted to the Hematology and Oncology A Service following her first course of chemotherapy. She had her last course of chemotherapy on MM/DD/YYYY followed by radiation treatment to the ethmoid sinuses on MM/DD/YYYY.

HOSPITAL COURSE:
1. Ewing sarcoma, she presented for cycle seven of VP-16, ifosfamide, and mesna infusions, which she tolerated well throughout the admission.
2. She was followed for hemorrhagic cystitis with urine dipsticks and only showed trace amounts of blood in the urine throughout the admission.

Keywords: discharge summary, iron deficiency anemia, hypertension and obesity, iron deficiency, urine, anemia, hypertension, chemotherapy, discharge, ewing, sarcoma,
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.
Home | MedicalTranscriptionSamples | MT911 | MTDictionary | MTSetup | MTHelpLine
Sitemap | Tell a Friend | Contact Us | Disclaimer

Transcribed Medical Transcription Sample Reports and Examples