Sample Name: Discharge Summary - Cholelithiasis
Description: Patient with complaint of symptomatic cholelithiasis.
(Medical Transcription Sample Report)
ADMISSION DIAGNOSIS: Symptomatic cholelithiasis.
DISCHARGE DIAGNOSIS: Symptomatic cholelithiasis.
HISTORY OF PRESENT ILLNESS: Ms. ABC is a 27-year-old woman who apparently presented with complaint of symptomatic cholelithiasis. She was afebrile. She was taken by Dr. X to the operating room.
DISCHARGE INSTRUCTIONS: Clear liquid diet x48 hours and she can return to her Medifast, she may shower. She needs to keep her wound clean and dry. She is not to engage in any heavy lifting greater than 10 pounds x2 weeks. No driving for 1 to 2 weeks. She must be able to stop in an emergency and be off narcotic meds, no strenuous activity, but she needs to maintain mobility. She can resume her medications per med rec sheets.
DISCHARGE MEDICATIONS: As previously mentioned.
FOLLOWUP: We will follow up on both urinalysis and cultures. She is instructed to follow up with Dr. X in 2 weeks. She needs to call for any shortness of breath, temperature greater than 101.5, chest pain, intractable nausea, vomiting, and abdominal pain, any redness, swelling or foul smelling drainage from her wounds.
Keywords: discharge summary, medifast, liquid diet, symptomatic cholelithiasis, symptomatic, cholelithiasis, discharge,