Sample Name: Discharge Summary - 10
Description: Patient with a history of a Nissen fundoplication performed six years ago for gastric reflux.
(Medical Transcription Sample Report)
ADMITTING DIAGNOSES: Hiatal hernia, gastroesophageal reflux disease reflux.
DISCHARGE DIAGNOSES: Hiatal hernia, gastroesophageal reflux disease reflux.
SECONDARY DIAGNOSIS: Postoperative ileus.
PROCEDURES DONE: Hiatal hernia repair and Nissen fundoplication revision.
BRIEF HISTORY: The patient is an 18-year-old male who has had a history of a Nissen fundoplication performed six years ago for gastric reflux. Approximately one year ago, he was involved in a motor vehicle accident and CT scan at that time showed that he had a hiatal hernia. Over the past year, this has caused him an increasing number of problems, including chest pain when he eats, and shortness of breath after large meals. He is also having reflux symptoms again. He presents to us for repair of the hiatal hernia and revision of the Nissen fundoplication.
DISCHARGE CONDITION: Stable.
DISPOSITION: Discharged to home.
DISCHARGE INSTRUCTIONS: The patient was discharged to home with instructions for maintaining a soft diet. It was also recommended that he does not drink any soda postoperatively. He is instructed to keep his incision site clean and dry and it was also recommended that he avoid any heavy lifting. He will be able to attend school when it starts in a few weeks. However, he is not going to be able to play football in the near future. He was given prescription for pain medication upon discharge. He is instructed to contact Pediatric Surgery if he has any fevers, any nausea and vomiting, any chest pain, any constipation, or any other concerns.
Keywords: discharge summary,