Sample Name: Abscess With Cellulitis - Discharge Summary

Sample Name: Abscess with Cellulitis - Discharge Summary
Description: Incision and drainage, first metatarsal head, left foot with culture and sensitivity.
(Medical Transcription Sample Report)
ADMITTING DIAGNOSIS: Abscess with cellulitis, left foot.
DISCHARGE DIAGNOSIS: Status post I&D, left foot.
PROCEDURES: Incision and drainage, first metatarsal head, left foot with culture and sensitivity.
HISTORY OF PRESENT ILLNESS: The patient presented to Dr. X's office on 06/14/07 complaining of a
painful left foot. The patient had been treated conservatively in office for approximately 5 days, but symptoms
progressed with the need of incision and drainage being decided.
MEDICATIONS: Ancef IV.
ALLERGIES: ACCUTANE.
SOCIAL HISTORY: Denies smoking or drinking.
PHYSICAL EXAMINATION: Palpable pedal pulses noted bilaterally. Capillary refill time less than 3
seconds, digits 1 through 5 bilateral. Skin supple and intact with positive hair growth. Epicritic sensation intact
bilateral. Muscle strength +5/5, dorsiflexors, plantar flexors, invertors, evertors. Left foot with erythema,
edema, positive tenderness noted, left forefoot area.
LABORATORY: White blood cell count never was abnormal. The remaining within normal limits. X-ray is
negative for osteomyelitis. On 06/14/07, the patient was taken to the OR for incision and drainage of left foot
abscess. The patient tolerated the procedure well and was admitted and placed on vancomycin 1 g q.12h after
surgery and later changed Ancef 2 g IV every 8 hours. Postop wound care consists of Aquacel Ag and dry
dressing to the surgical site everyday and the patient remains nonweightbearing on the left foot. The patient
progressively improved with IV antibiotics and local wound care and was discharged from the hospital on
06/19/07 in excellent condition.
DISCHARGE MEDICATIONS: Lorcet 10/650 mg, dispense 24 tablets, one tablet to be taken by mouth q.6h
as needed for pain. The patient was continued on Ancef 2 g IV via PICC line and home health administration of
IV antibiotics.
DISCHARGE INSTRUCTIONS: Included keeping the foot elevated with long periods of rest. The patient is
to wear surgical shoe at all times for ambulation and to avoid excessive ambulation. The patient to keep
dressing dry and intact, left foot. The patient to contact Dr. X for all followup care, if any problems arise. The
patient was given written and oral instruction about wound care before discharge. Prior to discharge, the patient
was noted to be afebrile. All vitals were stable. The patient's questions were answered and the patient was
discharged in apparent satisfactory condition. Followup care was given via Dr. X' office.
Sample Name: Cardio/Pulmo Discharge Summary
Description: A 49-year-old man with respiratory distress, history of coronary artery disease with prior myocardial
infarctions, and recently admitted with pneumonia and respiratory failure.
(Medical Transcription Sample Report)
ADMISSION DIAGNOSIS:
1. Respiratory arrest.
2 . End-stage chronic obstructive pulmonary disease.
3. Coronary artery disease.
4. History of hypertension.
DISCHARGE DIAGNOSIS:
1. Status post-respiratory arrest.
2. Chronic obstructive pulmonary disease.
3. Congestive heart failure.
4. History of coronary artery disease.
5. History of hypertension.
SUMMARY: The patient is a 49-year-old man who was admitted to the hospital in respiratory distress, and had to be
intubated shortly after admission to the emergency room. The patient’s past history is notable for a history of coronary
artery disease with prior myocardial infarctions in 1995 and 1999. The patient has recently been admitted to the hospital
with pneumonia and respiratory failure. The patient has been smoking up until three to four months previously. On the
day of admission, the patient had the sudden onset of severe dyspnea and called an ambulance. The patient denied any
gradual increase in wheezing, any increase in cough, any increase in chest pain, any increase in sputum prior to the
onset of his sudden dyspnea.
ADMISSION PHYSICAL EXAMINATION:

GENERAL: Showed a well-developed, slightly obese man who was in extremis.
NECK: Supple, with no jugular venous distension.

HEART: Showed tachycardia without murmurs or gallops.
PULMONARY: Status showed decreased breath sounds, but no clear-cut rales or wheezes.
EXTREMITIES: Free of edema.
HOSPITAL COURSE: The patient was admitted to the Special Care Unit and intubated. He received intravenous antibiotic
therapy with Levaquin. He received intravenous diuretic therapy. He received hand-held bronchodilator therapy. The
patient also was given intravenous steroid therapy with Solu-Medrol. The patient’s course was one of gradual
improvement, and after approximately three days, the patient was extubated. He continued to be quite dyspneic, with
wheezes as well as basilar rales. After pulmonary consultation was obtained, the pulmonary consultant felt that the
patient’s overall clinical picture suggested that he had a
significant element of congestive heart failure. With this, the patient was placed on increased doses of Lisinopril and
Digoxin, with improvement of his respiratory status. On the day of discharge, the patient had minimal basilar rales; his
chest also showed minimal expiratory wheezes; he had no edema; his heart rate was regular; his abdomen was soft; and
his neck veins were not distended. It was, therefore, felt that the patient was stable for further management on an
outpatient basis.
DIAGNOSTIC DATA: The patient’s admission laboratory data was notable for his initial blood gas, which showed a pH of
7.02 with a pCO2 of 118 and a pO2 of 103. The patient’s electrocardiogram showed nonspecific ST-T wave changes. The
patent’s CBC showed a white count of 24,000, with 56% neutrophils and 3% bands.
DISPOSITION: The patient was discharged home.
DISCHARGE INSTRUCTIONS: His diet was to be a 2 grams sodium, 1800 calorie ADA diet. His medications were to be
Prednisone 20 mg twice per day, Theo-24 400 mg per day, Furosemide 40 mg 1-1/2 tabs p.o. per day; Acetazolamide 250
mg one p.o. per day, Lisinopril 20 mg. one p.o. twice per day, Digoxin 0.125 mg one p.o. q.d., nitroglycerin paste 1 inch
h.s., K-Dur 60 mEq p.o. b.i.d. He was also to use a Ventolin inhaler every four hours as needed, and Azmacort four puffs
twice per day. He was asked to return for follow-up with Dr. X in one to two weeks. Arrangements have been made for
the patient to have an echocardiogram for further evaluation of his congestive heart failure later on the day of
discharge.

Sample Name: Abscess With Cellulitis - Discharge Summary

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Sample Name: Abscess with Cellulitis - Discharge Summary

ADMITTING DIAGNOSIS: Abscess with cellulitis, left foot.

DISCHARGE DIAGNOSIS: Status post I&D, left foot.

MEDICATIONS: Ancef IV.

SOCIAL HISTORY: Denies smoking or drinking.

ADMISSION PHYSICAL EXAMINATION:

NECK: Supple, with no jugular venous distension.

DISPOSITION: The patient was discharged home.

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