Medical Specialty:
Obstetrics / Gynecology

Sample Name: Hysterectomy - Discharge Summary - 1

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

1. Menometrorrhagia.
2. Dysmenorrhea.
3. Small uterine fibroids.

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.


Keywords: obstetrics / gynecology, dysmenorrhea, uterine fibroids, vaginal, total vaginal hysterectomy, menometrorrhagia, uterine, fibroids,