Sample Name: Discharge Summary - 5
Description: A female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity.
(Medical Transcription Sample Report)
DATE OF ADMISSION: MM/DD/YYYY.
DATE OF DISCHARGE: MM/DD/YYYY.
REFERRING PHYSICIAN: AB CD, M.D.
ATTENDING PHYSICIAN AT DISCHARGE: X Y, M.D.
1. Ewing sarcoma.
PROCEDURES DURING HOSPITALIZATION: Cycle seven Ifosfamide, mesna, and VP-16 chemotherapy.
HISTORY OF PRESENT ILLNESS: Ms. XXX is a pleasant 37-year-old African-American female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity. She presented initially with a left frontal orbital swelling to Dr. XYZ on MM/DD/YYYY. A biopsy revealed small round cells and repeat biopsy on MM/DD/YYYY also showed round cells consistent with Ewing sarcoma, genetic analysis indicated a T1122 translocation. MRI on MM/DD/YYYY showed a 4 cm soft tissue mass without bony destruction. CT showed similar result. The patient received her first cycle of chemotherapy on MM/DD/YYYY. On MM/DD/YYYY, she was admitted to the ED with nausea and vomitting and was admitted to the Hematology and Oncology A Service following her first course of chemotherapy. She had her last course of chemotherapy on MM/DD/YYYY followed by radiation treatment to the ethmoid sinuses on MM/DD/YYYY.
1. Ewing sarcoma, she presented for cycle seven of VP-16, ifosfamide, and mesna infusions, which she tolerated well throughout the admission.
Keywords: general medicine, iron deficiency anemia, hypertension and obesity, iron deficiency, urine, anemia, hypertension, chemotherapy, discharge, ewing, sarcoma,