Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Discharge Summary
Sample Name: Hysterectomy - Discharge Summary - 1

Description: Total vaginal hysterectomy. Menometrorrhagia, dysmenorrhea, and small uterine fibroids.
(Medical Transcription Sample Report)

ADMISSION DIAGNOSES:
1. Menometrorrhagia.
2. Dysmenorrhea.
3. Small uterine fibroids.

DISCHARGE DIAGNOSES:
1. Menorrhagia.
2. Dysmenorrhea.
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: Good.

Keywords: discharge summary, dysmenorrhea, uterine fibroids, vaginal, total vaginal hysterectomy, menometrorrhagia, uterine, fibroids,
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