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Discharge Summary Medical Transcription Transcribed Example / Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left lower extremity edema, possible infected graft.

CONSULTS OBTAINED:  Renal and ID consults obtained.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old male being admitted for left lower extremity leg pain, drainage, and redness.  The patient had an AV shunt placed about four months ago.  The patient recently had debridement of his left lower extremity wound in the OR.  The patient has had a wound VAC in place, being changed three times weekly, and the patient now presents to the vascular access center with a wound culture from two weeks back with VRE.  The patient was then seen and examined and was admitted for debridement and ligation of his AV shunt the following day.

PAST MEDICAL HISTORY:  End-stage renal disease, hypertension, insulin-dependent diabetes, hypothyroidism, and GERD.

PAST SURGICAL HISTORY:  Left BKA and hip replacement and ankle surgeries.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  The patient does not drink.  He smokes approximately 3 cigarettes per day.  He lives alone.

ALLERGIES:  HE IS ALLERGIC TO PENICILLIN.

REVIEW OF SYSTEMS:  SKIN:  Positive erythema. Positive open wound.  Left lower extremity with a wound VAC.  HEENT:  Wears glasses.  NECK:  Denies any neck pain.  CARDIOVASCULAR:  No chest pain.  No palpitations.  GASTROINTESTINAL:  Denies any abdominal pain, nausea or vomiting.  PULMONARY:  Denies shortness of breath.  GENITOURINARY:  The patient is chronic end-stage renal, on dialysis.  MUSCULOSKELETAL:  The patient has a right femoral PermCath.  The patient is in a wheelchair.  He has a left AV femoral shunt and a left BKA.  NEUROPSYCH:  Denies depression or anxiety.  ENDOCRINE:  Positive for diabetes.

PHYSICAL EXAMINATION:  VITAL SIGNS:  Upon admission, temperature 98.4, blood pressure 126/62, pulse 68, respirations 16, and O2 saturation 98% on room air.  GCS is 15.  The patient complains of left lower leg pain.  GENERAL:  Upon admission, in no acute distress.  Well-developed, well-nourished man seated in the wheelchair.  LUNGS:  Clear to auscultation bilaterally.  HEART:  S1 and S2 present.  Rate and rhythm regular.  ABDOMEN:  Soft and nontender, nondistended, with positive bowel sounds x4 quadrants.  No organomegaly.  EXTREMITIES:  The patient has a left lower extremity open wound, positive sloughing, limited granulation tissue.  Lower extremity is very edematous.  He has positive surrounding erythema.  He has positive thrill in his AV shunt, and his stump is very warm to the touch.  Right lower extremity, the patient has a femoral PermCath with no erythema, no drainage.  NEUROLOGIC:  The patient is alert and oriented x3.  Follows all commands and moves all extremities.

LABORATORY DATA:  The patient's labs prior to discharge; sodium 138, potassium 5.4, chloride 102, carbon dioxide 24, BUN 31, creatinine 7.5 and glucose 104.

HOSPITAL COURSE AND TREATMENT:  The patient was admitted to the floor.  He had stat labs.  Blood cultures were drawn.  Renal consult was obtained.  Also, an ID consult was obtained.  The patient was immediately started on IV antibiotics, which were linezolid and ceftriaxone.  The patient had a chest x-ray and EKG preoperatively and was taken to the operating room the next day for a debridement and ligation of his left AV shunt.  The patient tolerated the procedure well.  Wound VAC was placed on the wound and the patient was transferred back to the floor for continued observation.  He continued to improve.  Edema of his left lower extremity decreased tremendously.  He did have an episode of anemia, questionable acute blood loss anemia, due to the surgery or due to hemodialysis.  The patient, however, did not require any blood transfusions and his anemia improved over time.  The patient remained asymptomatic.  The patient also had a bout of hypertension.  He was continued on his previous at-home medications and he was observed and monitored.  His diabetes remained in control on Levemir 4 units subcutaneously.  He was able to tolerate a diet, able to move about without any difficulties.  ID consult was obtained, as the culture from the operating room was positive for Klebsiella pneumoniae and beta-hemolytic strep.  As the patient received IV antibiotics x4 days, it was felt that the patient could be given p.o. antibiotics at home, which would be doxycycline 200 mg p.o. loading dose and then 100 mg p.o. b.i.d., duration to be determined by clinical response.  The patient will be given a prescription for a 14-day regimen.  The patient will be seen a week after discharge.  The patient has a right femoral PermCath, which continues to function, and he will continue to use that for dialysis.  Upon discharge, the patient is afebrile.  His blood pressure is stable.  However, he does have some hypertension; it appears to be in the morning time, which was being monitored by renal services.  No changes were made.  As stated, the patient's left lower extremity edema is much improved.  His leg is soft with no erythema and his wound VAC is intact with no drainage, and he denies any tenderness to palpation.  He is able to tolerate a diet, and he is able to move about in his wheelchair without any difficulty.

DISCHARGE INSTRUCTIONS/MEDICATIONS:  The patient will be discharged to home with home health care services to change the wound VAC, as they had been doing prior to his admission.  Medications which the patient will take include Accupril 2.5 mg daily; folic acid 1 mg daily; Kayexalate 15 grams Sunday, Monday and Wednesday; Lopressor 50 mg two times daily; Synthroid 25 mcg daily; Levemir 4 units subcutaneously at night; and Renagel 2400 mg three times daily with meals.  The patient is instructed to stop taking Plavix.

His new medications at the time of discharge include Lortab 7.5/500 mg one every 6 hours as needed and doxycycline 200 mg x1 dose, then 100 mg two times daily x14 days.  The patient is to start that tomorrow.  Danger signs to watch for or should call the vascular access center with are temperature over 101, more unrelieved pain, any new swelling at the operative site, any redness or drainage or warmth at the operative site.  The patient is to continue with his wound VAC to his left lower extremity wound, to be changed on Monday, Wednesday and Friday.  Discharge diet is renal diabetic diet.  He may resume activities as he was doing prior to his admission.  He is to follow up with Dr. Doe in the vascular access center.  The patient is also to return to his regular dialysis schedule.  They were notified of the patient's discharge and he will continue.

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