Sample Name: Urology Discharge Summary
Description: Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction.
(Medical Transcription Sample Report)
PROCEDURES: Cystourethroscopy and transurethral resection of prostate.
ADMITTING DIAGNOSIS: Difficulty voiding.
HISTORY: This 67-year old Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction. Physical examination revealed normal heart and lungs. Abdomen was negative for abnormal findings.
LABORATORY DATA: BUN 19 and creatinine 1.1. Blood group was A, Rh positive, Hemoglobin 13, Hematocrit 32.1, Prothrombin time 12.6 seconds, PTT 37.1. Discharge hemoglobin 11.4, and hematocrit 33.3. Chest x-ray calcified old granulomatous disease, otherwise normal. EKG was normal.
DISCHARGE DIAGNOSIS: Enlarged prostate with benign bladder neck obstruction.
To be followed in my office in one week and by Dr. ABC next available as an outpatient.
Keywords: discharge summary, tur, bun, cystourethroscopy, difficulty voiding, bladder neck obstruction, creatinine, cysto, enlarged prostate, transurethral resection of prostate, urinary stream, bladder neck, neck obstruction, prostate,