Medical Specialty:
Discharge Summary
Sample Name: Neurology - Discharge Summary
Description: Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.
(Medical Transcription Sample Report)
PRELIMINARY DIAGNOSES:
1. Contusion of the frontal lobe of the brain.
2. Closed head injury and history of fall.
3. Headache, probably secondary to contusion.
FINAL DIAGNOSES:
1. Contusion of the orbital surface of the frontal lobes bilaterally.
2. Closed head injury.
3. History of fall.
PLAN: Discharge the patient to home.
ACTIVITY: As tolerated.
The patient has been advised to call if the headache is recurrent and Tylenol 650 mg 1 p.o. q.6 h. p.r.n. headache. The patient has been advised to follow up with me as well as the neurologist in about 1 week.
Keywords: discharge summary, interhemispheric, frontal lobe, head injury, brain, contusion,