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: Pyelonephritis - Discharge Summary

Description: Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.
(Medical Transcription Sample Report)

ADMISSION DIAGNOSES:
1. Pyelonephritis.
2. History of uterine cancer and ileal conduit urinary diversion.
3. Hypertension.
4. Renal insufficiency.
5. Anemia.

DISCHARGE DIAGNOSES:
1. Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit.
2. Hypertension.
3. Mild renal insufficiency.
4. Anemia, which has been present chronically over the past year.

HOSPITAL COURSE: The patient was admitted with suspected pyelonephritis. Renal was consulted. It was thought that there was a thick mucous plug in the Foley in the ileal conduit that was irrigated by Dr. X. Her symptoms responded to IV antibiotics and she remained clinically stable. Klebsiella was isolated in this urine, which was sensitive to Bactrim and she was discharged on p.o. Bactrim. She was scheduled on 08/07/2007 for further surgery. She is to follow up with Dr. Y in 7-10 days. She also complained of right knee pain and the right knee showed no sign of effusion. She was exquisitely tender to touch of the patellar tendon. It was thought that this did not represent intraarticular process. She was advised to use ibuprofen over-the-counter two to three tabs t.i.d.

Keywords: discharge summary, uterine cancer, renal insufficiency, pyelonephritis, mucous plugging, ileal conduit,
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