Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples

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Sample Type / Medical Specialty: Discharge Summary
Sample Name: BRCA-2 mutation

Description: Discharge summary of a patient with a BRCA-2 mutation.
(Medical Transcription Sample Report)


HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old with a BRCA-2 mutation. Her sister died of breast cancer at age 32 and her daughter had breast cancer at age 27.

PHYSICAL EXAMINATION: The chest was clear. The abdomen was nontender. Pelvic examination shows no masses. No heart murmur.

HOSPITAL COURSE: The patient underwent surgery on the day of admission. In the postoperative course she was afebrile and unremarkable. The patient regained bowel function and was discharged on the morning of the fourth postoperative day.

OPERATIONS AND PROCEDURES: Total abdominal hysterectomy/bilateral salpingo-oophorectomy with resection of ovarian fossa peritoneum en bloc on July 25, 2006.

PATHOLOGY: A 105-gram uterus without dysplasia or cancer.


PLAN: The patient will remain at rest initially with progressive ambulation after. She will avoid lifting, driving or intercourse. She will call me if any fevers, drainage, bleeding, or pain. Follow up in my office in four weeks. Family history, social history, psychosocial needs per the social worker.

DISCHARGE MEDICATIONS: Percocet 5 #40 one every 3 hours p.r.n. pain.

Keywords: discharge summary, brca-2 mutation, brca-2, mutation, breast cancer, brca mutation, breast, postoperative, peritoneum, brca, discharge, cancer,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples