Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Urology
Sample Name: Urology Discharge Summary

Description: Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction.
(Medical Transcription Sample Report)

PROCEDURES: Cystourethroscopy and transurethral resection of prostate.

COMPLICATIONS: None.

ADMITTING DIAGNOSIS: Difficulty voiding.

HISTORY: This 67-year old Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction. Physical examination revealed normal heart and lungs. Abdomen was negative for abnormal findings.

LABORATORY DATA: BUN 19 and creatinine 1.1. Blood group was A, Rh positive, Hemoglobin 13, Hematocrit 32.1, Prothrombin time 12.6 seconds, PTT 37.1. Discharge hemoglobin 11.4, and hematocrit 33.3. Chest x-ray calcified old granulomatous disease, otherwise normal. EKG was normal.

COURSE IN THE HOSPITAL: The patient had a cysto and TUR of the prostate. Postoperative course was uncomplicated. The pathology report is pending at the time of dictation. He is being discharged in satisfactory condition with a good urinary stream, minimal hematuria, and on Bactrim DS one a day for ten days with a standard postprostatic surgery instruction sheet.

DISCHARGE DIAGNOSIS: Enlarged prostate with benign bladder neck obstruction.

To be followed in my office in one week and by Dr. ABC next available as an outpatient.

Keywords: urology, tur, bun, cystourethroscopy, difficulty voiding, bladder neck obstruction, creatinine, cysto, enlarged prostate, transurethral resection of prostate, urinary stream, bladder neck, neck obstruction, prostate,
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