Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Discharge Summary Transcribed Sample Report

DATE OF ADMISSION:  MM/DD/YYYY


DATE OF DISCHARGE:  MM/DD/YYYY


DISCHARGE DIAGNOSES:
1.  Hypovolemia.
2.  Protein-calorie malnutrition.
3.  Pneumonia.
4.  Urinary tract infection.
5.  Clostridium difficile infection.
6.  Respiratory failure.
7.  Head and neck cancer.


PROCEDURES DONE DURING THIS ADMISSION:  Temporary tracheostomy.


HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male with a history of right retromolar squamous cell carcinoma of the head and neck, status post local resection and two courses of radiation therapy followed by hyperbaric treatment for nonhealing ulcer that has subsequently recurred.  He has been felt to be a nonsurgical candidate.  He has increasing difficulty in opening or closing his mouth, maintained on liquid diet at home with pain medication and oral nutrition.  He is in danger though of airway obstruction and compromise, and he has been admitted for placement of a feeding tube and to evaluate his nutrition and treat his pain, as well as his dehydration.


HOSPITAL COURSE:  Upon admission, the patient was admitted and placed on IV fluids.  Labs were obtained.  Continued home medications, methadone elixir and oxycodone elixir.  Consult was made to the surgeon, Dr. John Doe, with regard to the patient's need for a port as well as G-tube placement and a consult was made to the ear, nose, and throat specialist, Dr. Jane Doe, with patient need for a tracheostomy.  On MM/DD/YYYY, the patient was seen by the surgeon, Dr. John Doe, and after his assessment; impression, history of head and neck cancer with metastatic disease status post radiation therapy, inability to open mouth, and chronic pain.  The patient and his wife were present.  I told them that this is a very difficult situation due to the fact that he is unable to open his mouth and it would be impossible to obtain an airway orally.  He would have to consider tracheostomy, which could have been done under sedation, then followed obviously by gastrostomy placement, which would require an incision of his abdominal wall, and there are certain risks associated with that including bleeding, infection, scarring, leakage, and abscess.  All of this has been discussed.  Particularly, because of his nutritional status, we also discussed port placement, which could be done.  Risks though would include bleeding, infection, scarring, and pneumothorax and obviously high risk of infection if he has a tracheostomy placed.  The other possibility for feeding purposes would be to consider radiologic placement nasally of a Dobbhoff feeding tube, which could be done by radiology department if they evaluate him and feel that it could be done.  On MM/DD/YYYY, the patient underwent tracheostomy by Dr. Doe.  Postoperatively, he was monitored in the ICU and given morphine sulfate for narcotic analgesia.  The patient did opt for the placement of nasogastric tube under fluoroscopy with percutaneous placement of gastrostomy tube under fluoroscopy under physician monitored conscious sedation.  Post-placement, he was then started on Jevity tube feedings.  A consult was made to the IV team for placement of PICC line and this was placed for IV access.  Because of his overall poor condition, the patient and his wife considered hospice with comfort care measures only.  He was made a DNR with full active treatment.  A consult was then made to hospice for post-discharge care, and arrangements were made for the patient to be discharged home under the care of hospice.  He continued to be supported with medications for pain, transfusion of blood and platelets, and tube feeding for nutritional support.  Once arrangements were made for discharge home with hospice, the PICC line was discontinued, and the patient was discharged home under the care of hospice.