Medical Specialty: Discharge Summary

A clinical report prepared by a physician or other health professional at the conclusion of a hospital stay or series of treatments. It outlines the patient's chief complaint, the diagnostic findings, the therapy administered and the patient's response to it, and recommendations on discharge.

Discharge Summary
Abscess with Cellulitis - Discharge Summary
Incision and drainage, first metatarsal head, left foot with culture and sensitivity.
Anterior Cervical Discectomy & Fusion - Discharge Summary
Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.
Back & Leg Pain - Discharge Summary
Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy. Chronic pain syndrome.
Back Pain - Discharge Summary
Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.
BRCA-2 mutation
Discharge summary of a patient with a BRCA-2 mutation.
Bronchiolitis - Discharge Summary
Bronchiolitis, respiratory syncytial virus positive; improved and stable. Innocent heart murmur, stable.
Cardiac Transfer Summary
Need for cardiac catheterization. Coronary artery disease, chest pain, history of diabetes, history of hypertension, history of obesity, a 1.1 cm lesion in the medial aspect of the right parietal lobe, and deconditioning.
Cardio/Pulmo Discharge Summary
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.
Cellulitis - Discharge Summary
Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis. The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound.
Chest Pain & Respiratory Insufficiency
A lady was admitted to the hospital with chest pain and respiratory insufficiency. She has chronic lung disease with bronchospastic angina.
CHF & Pleural Effusion - Discharge Summary
Congestive heart failure (CHF) with left pleural effusion. Anemia of chronic disease.
Cholecystitis - Discharge Summary
Cholecystitis with choledocholithiasis. Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction.
Cholestasis Of Pregnancy
Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress. Primary low transverse cesarean section.
Chronic Abscesses - Discharge Summary
Multiple extensive subcutaneous abscesses, right thigh. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.
Cognitive Linguistic Impairment - Discharge
Cognitive linguistic impairment secondary to stroke. The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.
COPD - Discharge Summary
A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath.
COPD & Bronchitis - Discharge Summary
Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.
CVA - Discharge Summary
Cerebrovascular accident (CVA) with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect. 2. Old coronary infarct, anterior aspect of the right external capsule. Acute bronchitis with reactive airway disease.
D&C - Discharge Summary
Hysteroscopy, dilatation and curettage (D&C), and myomectomy. Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and fibroid uterus.
Death Summary
Death summary of an 80-year-old patient with a history of COPD.
Death Summary - 1
Death summary of patient with advanced non-small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis.
Death Summary - 2
Cardiac arrest, severe congestive heart failure, acute on chronic respiratory failure, osteoporosis, and depression.
Discharge Summary
Patient had some cold symptoms, was treated as bronchitis with antibiotics.
Discharge Summary - 1
Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe, hypertension, urinary tract infection, and hypercholesterolemia.
Discharge Summary - 10
Patient with a history of a Nissen fundoplication performed six years ago for gastric reflux.
Discharge Summary - 11
Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.
Discharge Summary - 12
A 94-year-old female from the nursing home with several days of lethargy and anorexia. She was found to have evidence of UTI and also has renal insufficiency and digitalis toxicity.
Discharge Summary - 13
Bradycardia, dizziness, diabetes, hypertension, abdominal pain, and sick sinus syndrome.
Discharge Summary - 14
The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat.
Discharge Summary - 15
Gastroenteritis and autism. She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved.
Discharge Summary - 16
Upper respiratory illness with apnea, possible pertussis. a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. This involved cough, post-tussive emesis, and questionable fever.
Discharge Summary - 17
The patient underwent a scalp skin biopsy with pathology specimen obtained. At the time of discharge, the patient had improved.
Discharge Summary - 18
The patient is a 53-year-old woman with history of hypertension, diabetes, and depression. Serotonin syndrome secondary to high doses of Prozac and atypical chest pain with myocardial infarction ruled out.
Discharge Summary - 19
The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.
Discharge Summary - 2
Patient with complaints of shortness of breath and was found to have acute COPD exacerbation.
Discharge Summary - 3
Patient with increased shortness of breath of one day duration.
Discharge Summary - 4
Patient admitted after an extensive workup for peritoneal carcinomatosis from appendiceal primary.
Discharge Summary - 5
A female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity.
Discharge Summary - 6
A white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital.
Discharge Summary - 7
Patient with fever of unknown origin.
Discharge Summary - 8
A white female with a history of fevers.
Discharge Summary - 9
A woman presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months.
Discharge Summary - ATV Accident
Trauma/ATV accident resulting in left open humerus fracture.
Discharge Summary - Cerebral Palsy
a pleasant 62-year-old male with cerebral palsy
Discharge Summary - Cholelithiasis
Patient with complaint of symptomatic cholelithiasis.
Discharge Summary - COPD
Chest x-ray on admission, no acute finding, no interval change. CT angiography, negative for pulmonary arterial embolism. Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.
Discharge Summary - Gastric Bypass
Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success.
Discharge Summary - Hemodialysis
The patient is being discharged for continued hemodialysis and rehab.
Discharge Summary - Hip Surgery
A 47-year-old female with a posttraumatic AV in the right femoral head.
Discharge Summary - Lymphoma
Diffuse Large B-cell Lymphoma
Discharge Summary - Mesothelioma
A patient with preoperative diagnosis of right pleural mass and postoperative diagnosis of mesothelioma.
Discharge Summary - Mesothelioma - 1
Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.
Discharge Summary - Migraine
Intractable migraine with aura. The patient is discharged home. Secondary diagnoses are Bipolar disorder, iron deficiency anemia, anxiety disorder, and history of tubal ligation.
Discharge Summary - Multiple Trauma
Aftercare of multiple trauma from an motor vehicle accident.
Discharge Summary - Nephrology
Patient with left renal cell carcinoma, left renal cyst, had robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.
Discharge Summary - Peripheral vascular disease
The patient with multiple medical conditions including coronary artery disease, hypothyroidism, and severe peripheral vascular disease status post multiple revascularizations.
Discharge Summary - Respiratory Distress
A 3-year-old abrupt onset of cough and increased work of breathing.
Discharge Summary - Respiratory Failure
The patient was admitted after undergoing a drawn out process with a small bowel obstruction.
Discharge Summary - Urology
Discharge Summary of a patient with hematuria, benign prostatic hyperplasia, complex renal cyst versus renal cell carcinoma, and osteoarthritis.
Discharge Summary - Urology & Nephrology
Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.
Ectopic Pregnancy - Discharge Summary
A 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. Right ruptured ectopic pregnancy with hemoperitoneum. Anemia secondary to blood loss.
ER Report - Chest Pain & Fever
A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin.
ESRD - Discharge Summary
This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis and is also status post cadaveric kidney transplant with chronic rejection.
Falls - Discharge Summary
Falls at home. Anxiety and depression. The patient had been increasingly anxious and freely admitted that she was depressed at home.
Gastric Bypass Summary
Patient discharged after laparoscopic Roux-en-Y gastric bypass.
Gastroenteritis - Discharge Summary
Acute gastroenteritis, resolved. Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.
Gastrointestinal Bleed - Discharge Summary
Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids. Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.
GI Bleed - Discharge Summary
GI bleed. Upper gastrointestinal bleed. CBC revealed microcytic anemia.
Goldenhar Syndrome - Discharge Summary
Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency.
Hemiarthroplasty - Discharge Summary
Hemiarthroplasty, right hip. Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.
Hip Surgery - Discharge Summar
Decreased ability to perform daily living activity secondary to recent right hip surgery.
Hypothermia - Discharge Summary
Hypothermia. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative. Organic brain syndrome. Seizure disorder. Adrenal insufficiency. Hypothyroidism. Anemia of chronic disease.
Hysterectomy - Discharge Summary
The patient underwent a total vaginal hysterectomy.
Hysterectomy - Discharge Summary - 1
Total vaginal hysterectomy. Menometrorrhagia, dysmenorrhea, and small uterine fibroids.
Hysterectomy - Discharge Summary - 2
Total vaginal hysterectomy. Microinvasive carcinoma of the cervix.
Intrauterine Pregnancy - Discharge Summary
Intrauterine pregnancy at term with previous cesarean. Desired sterilization. Status post repeat low transverse cesarean and bilateral tubal ligation.
Kawasaki Disease - Discharge Summary
This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.
Knee Arthroplasty - Discharge Summary
Painful right knee status post total knee arthroplasty many years ago. Status post poly exchange, right knee, total knee arthroplasty.
Knee Osteoarthrosis - Discharge Summary
A 66-year-old female with knee osteoarthrosis who failed conservative management.
Knee Surgery - Discharge Summary
Decreased ability to perform daily living activities secondary to right knee surgery.
Lap Chole - Discharge Summary
Laparoscopic cholecystectomy. Acute cholecystitis, status post laparoscopic cholecystectomy, end-stage renal disease on hemodialysis, hyperlipidemia, hypertension, congestive heart failure, skin lymphoma 5 years ago, and hypothyroidism.
Laryngitis - Discharge
Chronic laryngitis, hoarseness. The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.
Discharge summary of patient with leiomyosarcoma and history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia.
Mastoiditis - Discharge Summary
Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.
Mullerian Adenosarcoma
Discharge summary of a patient presenting with a large mass aborted through the cervix.
Multiple Medical Problems - Discharge Summary
Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, and congestive heart failure.
Neck Pain - Discharge Summary
Neck pain with right upper extremity radiculopathy and cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.
Neonatal Discharge Summary
The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation. Mother had two previous C-sections.
Neonatal Discharge Summary - 1
Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity. The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.
Neurology - Discharge Summary
Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.
Occupational Therapy Discharge Summary
Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.
ORIF - Discharge Summary
Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.
Otitis Media - Discharge Summary
Fever, otitis media, and possible sepsis.
Pancreatic Mass - Discharge Summary
The patient has had abdominal pain associated with a 30-pound weight loss and then developed jaundice. He had epigastric pain and was admitted to the hospital. A thin-slice CT scan was performed, which revealed a pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases.
Pneumonia - Discharge Summary
Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency. This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.
Pneumonia & COPD - Discharge Summary
Aspiration pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation. Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation. Systemic inflammatory response syndrome secondary to aspiration pneumonia. No bacteria identified with blood cultures or sputum culture.
Post Thyroidectomy - Discharge Summary
Symptomatic thyroid goiter. Total thyroidectomy.
Prematurity - Discharge Summary
Prematurity, 34 weeks' gestation, now 5 days old, group B streptococcus exposure, but no sepsis, physiologic jaundice, and feeding problem.
Psychiatric Discharge Summary
The patient was discharged by court as a voluntary drop by prosecution.
Psychiatric Discharge Summary - 1
Discharge summary of a patient with mood swings and oppositional and defiant behavior.
Psychiatric Discharge Summary - 2
Discharge summary of a patient with depression and high risk behavior.
Pyelonephritis - Discharge Summary
Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.
Renal Disease - Discharge Summary
Syncope, end-stage renal disease requiring hemodialysis, congestive heart failure, and hypertension.
Speech Therapy - Discharge Summary
Speech therapy discharge summary. The patient was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.
Speech Therapy - Discharge Summary - 1
The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.
Speech Therapy - Discharge Summary - 2
The patient was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke. The patient attended nine outpatient skilled speech therapy sessions.
TAH - Discharge Summary
Total abdominal hysterectomy (TAH). Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and symptomatic fibroid uterus.
Urology Discharge Summary
Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction.