She was set up with a skilled nursing facility, which took several days to arrange, where she was to be given daily physical therapy and rehabilitation until appropriate for her previous residence.
Social work was consulted with regard to arranging hospice care at home. While walking, she accidentally fell to her knees and did hit her head on the ground, near her left eye.
The patient came to the ER for an episode of vertigo while reaching for some books. The patient received ampicillin and gentamicin for 5 days worth of 10 doses of ampicillin, and blood cultures remained negative.
Review of systems otherwise unremarkable. Has renal insufficiency and elevated BUN and creatinine and currently undergoing evaluation by Dr. Resume activity as tolerated. This revealed concentric left ventricular hypertrophy present with normal left ventricular systolic function noted.
Initial examination showed bruising around the left eye, normal lung examination, normal heart examination, normal neurologic function with a baseline decreased mobility of her left arm. The patient does have a history of previous falls, one of which resulted in a hip fracture.
The patient was extubated the next day and placed on nasal cannula. He recommended Prevacid, and the Reglan was continued. He had been in stable condition as of late until about one month ago when he started to develop symptoms of increasing shortness of breath. Atrial fibrillation with subtherapeutic INR.
He was able to ambulate up to 40 feet with a single point cane with minimal to moderate assistance. No masses or tenderness appreciated.
The patient was then treated with single-agent irinotecan CPTbut despite treatment, he continued to have jaundice, elevated bilirubin, and progressive metastatic disease to the liver. Left upper extremity is held in a flexor synergy pattern and left elbow lacks 46 degrees to full extension.
There were no acute issues regarding the gout. He is now able to tolerate an air cast to his left upper extremity for prolonged periods of time.
The patient also had a head CT which showed atrophy with old ischemic changes. No acute intracranial findings. Her fall was not observed, but the patient does not profess any loss of consciousness, recalling the entire event. He is now able to tolerate a bivalved elbow cast with an inflatable handcuff.
Sodiumpotassium 4. The patient was placed on the community-acquired pneumonia protocol and treated with IV antibiotics. He presented to the emergency department where he was noted to have a right upper lobe infiltrate and a new right pleural effusion. Doe was of the opinion that the patient himself takes care of the Coumadin, and Dr.
Clarinex 5 mg daily. The patient is a pleasant, cooperative man. History of chronic obstructive pulmonary disease. He will also receive home speech, occupational and physical therapy through the VNA.
Pupils are equal, round and reactive to light. He was able to go up and down one flight of stairs with contact guard assistance, occasionally needing minimal assistance. He also had autonomic instability.
BAL was positive for Stenotrophomonas, and the patient was transferred to XX on vancomycin, cefepime, nafcillin and Bactrim. Doe was of the opinion that the patient does not need any further cardiac recommendation.Transcribed medical transcription discharge summary work type example reports for reference by medical transcriptionists and allied health professionals.
Transcribed medical transcription lung malignancy hematology/oncology discharge summary example report for reference by medical transcriptionists. A Discharge Summary provides an overview of a patient’s hospitalization from admission through discharge. It can be a few brief paragraphs or a multipage report, depending on the complexity of the patient’s condition and treatment.
Consultation Report Moreno. 1 pages. Operative Report Rolen 1 Fortis Institute, Towson DISCHARGE SUMMARY 1. 2 pages. History and Physical Examination Moreno This is a transcription class. I can only find the radiology report on here for this; Back to Department. Tweet.
Transcribed medical transcription neonatal discharge summary example report for reference by medical transcriptionists and allied health professionals. T J Moreno Discharge Summary Report Transcription Summary of the Transcription Process Anyone who has studied with me privately or in a master class situation, whether advanced or not are aware of my feelings about transcribing solos.
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