Sample Type / Medical Specialty: Discharge Summary
Sample Name: Hysterectomy - Discharge Summary - 1
Total vaginal hysterectomy. Menometrorrhagia, dysmenorrhea, and small uterine fibroids.
(Medical Transcription Sample Report)
3. Small uterine fibroids.DISCHARGE DIAGNOSES:
3. Small uterine fibroids.OPERATION PERFORMED:
Total vaginal hysterectomy.BRIEF HISTORY AND PHYSICAL:
The patient is a 42 year-old white female, gravida 3, para 2, with two prior vaginal deliveries. She is having increasing menometrorrhagia and dysmenorrhea. Ultrasound shows a small uterine fibroid. She has failed oral contraceptives and surgical therapy is planned.PAST HISTORY:
Significant for reflux.SURGICAL HISTORY:
Tubal ligation.PHYSICAL EXAMINATION:
A top normal sized uterus with normal adnexa.LABORATORY VALUES:
Her discharge hemoglobin is 12.4.HOSPITAL COURSE:
She was taken to the operating room on 11/05/07 where a total vaginal hysterectomy was performed under general anesthesia. Postoperatively, she has done well. Bowel and bladder function have returned normally. She is ambulating well, tolerating a regular diet. Routine postoperative instructions given and said follow up will be in four weeks in the office.DISCHARGE MEDICATIONS:
Preoperative meds plus Vicodin for pain.DISCHARGE CONDITION:
discharge summary, dysmenorrhea, uterine fibroids, vaginal, total vaginal hysterectomy, menometrorrhagia, uterine, fibroids,
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