Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Hematology - Oncology
Sample Name: Mullerian Adenosarcoma

Description: Discharge summary of a patient presenting with a large mass aborted through the cervix.
(Medical Transcription Sample Report)

PRINCIPAL DIAGNOSIS: Mullerian adenosarcoma.

HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old presenting with a large mass aborted through the cervix.

PHYSICAL EXAM:
CHEST: Clear. There is no heart murmur.
ABDOMEN: Nontender.
PELVIC: There is a large mass in the vagina.

HOSPITAL COURSE: The patient went to surgery on the day of admission. The postoperative course was marked by fever and ileus. The patient regained bowel function. She was discharged on the morning of the seventh postoperative day.

OPERATIONS: July 25, 2006: Total abdominal hysterectomy, bilateral salpingo-oophorectomy.

DISCHARGE CONDITION: Stable.

PLAN: The patient will remain at rest initially with progressive ambulation thereafter. She will avoid lifting, driving, stairs, or intercourse. She will call me for fevers, drainage, bleeding, or pain. Family history, social history, and psychosocial needs per the social worker. The patient will follow up in my office in one week.

PATHOLOGY: Mullerian adenosarcoma.

MEDICATIONS: Percocet 5, #40, one q.3 h. p.r.n. pain.

Keywords: hematology - oncology, cervix, fevers, drainage, bleeding, mullerian adenosarcoma, mullerian, adenosarcoma,
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