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.
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.
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,