DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. Gastrointestinal bleed.
2. Anemia secondary to gastrointestinal bleed.
3. Gastritis.
4. Angina.
5. Coronary artery disease.
6. Hypertension.
7. Hypothyroidism.
8. Hypercholesterolemia.
9. Diabetes mellitus.
PROCEDURES PERFORMED: EGD and colonoscopy.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male with a history of coronary artery disease, status post CABG, hypothyroidism, hypertension, insulin-dependent diabetes mellitus, hypercholesterolemia, and history of gastritis. The patient was admitted to the emergency room with chest pain. In the emergency room, he was found to have anemia and he had heme-positive stool. The patient reportedly had upper endoscopy five years ago, which showed gastritis.
ALLERGIES: None.
PREVIOUS HOSPITALIZATIONS: He had previous cholecystectomy, appendectomy, and CABG.
MEDICATIONS ON ADMISSION: Levoxyl 0.2 mg alternating with 0.125 mg daily, metoprolol 25 mg p.o. b.i.d., isosorbide 10 mg p.o. b.i.d., Avapro 150 mg p.o. daily, tramadol 50 mg p.o. q.8h., digoxin 0.25 mg p.o. q.o.d., Lipitor 20 mg p.o. daily, Aciphex 20 mg p.o. daily, baby aspirin one p.o. daily, nitroglycerin, insulin NPH 12 units subcutaneously q.a.m., Flexeril 5 mg p.o. daily, and Zantac 75 mg p.o. daily.
PAST MEDICAL HISTORY: As mentioned above.
PHYSICAL EXAMINATION: VITAL SIGNS: Initially, the patient’s temperature was 98.6, pulse 76, respiratory rate 20, and blood pressure 140/86.
LABORATORY DATA: Hemoglobin 9.2 and hematocrit 27.6. Initial troponin was less than 0.1.
HOSPITAL COURSE: The patient was admitted. He was seen by the cardiologist, and cardiac enzymes were obtained. He was cleared for upper and lower endoscopy. Upper endoscopy showed gastritis. The patient was admitted. During this admission, Avapro and insulin were held for the procedure. His blood sugars were monitored. The patient was discharged. He was to take no ASA or NSAIDs. He is to start Prevacid 30 mg p.o. daily. He is to see Dr. John Doe in four weeks. He is to see Dr. Jane Doe in two weeks. His hemoglobin was stable at the time of discharge. As far as pertinent labs, as mentioned, the patient’s cardiac enzymes were negative. His digoxin level was 0.7. He had a vitamin B12 level of 270. He had a ferritin level of 322. His lowest hemoglobin was 8.8.
GI Medical Transcription Discharge Summary Sample Report #2
CHIEF COMPLAINT: Nausea and vomiting.
ADMITTING DIAGNOSES:
1. Gastroenteritis.
2. Hypertension.
3. Congestive heart failure.
FINAL DIAGNOSES:
1. Gastroenteritis.
2. Hypertension.
3. Congestive heart failure.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female with history of hypertension, CHF, arthritis, peripheral vascular disease, and hypercholesterolemia who was admitted as she was having generalized weakness associated with nausea, vomiting, and diarrhea for the last two days, and she was admitted for further treatment.
PAST MEDICAL HISTORY: Hypertension, congestive heart failure, peripheral vascular disease, and hypercholesterolemia.
MEDICATIONS: The patient is on Protonix, sotalol 80 mg once a day, Coreg twice a day, Bextra 20 mg once a day, Lipitor 20 mg once a day, and Hyzaar 100/50 mg once a day.
PHYSICAL EXAMINATION: VITAL SIGNS: On admission, temperature was 98.6, blood pressure 132/82, respirations 18, and pulse 76. Rest of the examination was within normal limits.
LABORATORIES ON ADMISSION: Serial EKG showed pacemaker rhythm. Rest of the labs were within normal limits.
HOSPITAL COURSE: The patient was treated with Levaquin 500 mg once a day, Protonix once a day, and all other medications, sotalol, Coreg, Lipitor, and Hyzaar. Once her general condition improves and diarrhea stops, she will be discharged on Maalox, and we will follow up as outpatient.
GI Medical Transcription Discharge Summary Sample Report #3
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMISSION DIAGNOSES:
1. Intractable nausea.
2. Vomiting.
3. Epigastric pain.
DISCHARGE DIAGNOSES:
1. Intractable nausea.
2. Vomiting.
3. Epigastric pain.
4. Pancreatitis, resolved.
5. Hiatal hernia.
HOSPITAL COURSE: On admission, the patient was seen in GI consult. Their impression was that this is a patient with abdominal discomfort, nausea, vomiting, and episodes of loose bowel movements. X-rays performed were not consistent with obstruction. Possible gastroenteritis, which may explain the mild elevation of lipase versus a resolving pancreatitis to rule out gastric pathology.
At that stage, the patient seemed to be improving and noted he would begin clear liquids and progress as tolerated and obtain repeat abdominal x-rays the following morning and begin on Reglan IV piggyback, and depending on the patient’s clinical status, further workup could be determined as necessary. On MM/DD/YYYY, the patient was noted to be confused and disoriented the night previous. Much better that morning on rounds. Abdominal pain was much better. She was tolerating liquids. Her abdomen was soft and nontender. Her lipase was elevated, and she was assessed that day with pancreatitis, resolving. On MM/DD/YYYY, she had more confusion the night previous, still somewhat confused on MM/DD/YYYY. Her husband stated that this had been a problem at home. Tender upper abdomen assessed that day with pancreatitis, atrophy, congestive heart failure, compensated, and sundowning. She had an EGD done on MM/DD/YYYY showing a hiatal hernia. On MM/DD/YYYY, all of her symptoms were resolved at that time, and she was considered stable for discharge. The patient was discharged to be followed up in two weeks.
DISCHARGE MEDICATIONS: Discharged home on diltiazem CD 240 mg one daily, Reglan 10 mg half tablet q.i.d., lisinopril 20 mg one daily, Lasix 20 mg, and warfarin 5 mg half tablet q.a.m.
GI Medical Transcription Discharge Summary Sample Report #4
CHIEF COMPLAINT: Right upper quadrant pain and dyspnea.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female with a past medical history of hypertension, anemia, and goiter who presented with one-day history of sharp right upper quadrant and epigastric pain and dyspnea.
PAST MEDICAL HISTORY: Hypertension, anemia, goiter, and small bowel obstruction.
ALLERGIES: No known allergies.
HOSPITAL COURSE: In view of her advanced age and past medical history, the patient was admitted to telemetry for rule out MI. Chest x-ray showed increased perihilar markings without infiltrate. Obstructive series was done, which did not show any air fluid levels. Ultrasound showed gallstones with no evidence of cholecystitis. CT of the chest was done, which showed bilateral pleural effusions and atelectasis without evidence of pulmonary embolism. Cardiac enzymes x3 were obtained. The patient ruled out for acute MI. She was started on aspirin, beta-blocker, and nitroglycerin. Echocardiogram was done, and cardiology was consulted.
Gallstones were found on abdominal ultrasound, which were asymptotic. Echocardiogram showed moderately reduced left ventricular function and some evidence of diastolic dysfunction. The patient also had moderate to severe aortic valve sclerosis. She was placed on IV Lasix and ACE inhibitor and symptomatically improved with the above treatment. GI was consulted for anemia evaluation, and this workup will be continued as an outpatient. She was discharged to home to go and live with her niece and will follow up as an outpatient.
DISCHARGE MEDICATIONS: Lasix 40 mg daily, K-Dur 20 mEq daily, enalapril 5 mg daily, Lopressor 50 mg twice daily, and Imdur 30 mg daily.
GI Medical Transcription Discharge Summary Sample Report #5
HISTORY OF PRESENT ILLNESS: The patient was admitted with abdominal pain. The patient has a past history of esophagitis, erosive gastritis for which he is supposed to be taking medicines as an outpatient; however, he is extremely noncompliant. He comes to the emergency room with the above-mentioned pain. He has not had bowel movements. He has a history of IVDA.
PHYSICAL EXAMINATION: GENERAL: The patient is afebrile. VITAL SIGNS: Stable. ABDOMEN: There is diffuse, mild tenderness.
LABORATORY DATA: Hemoglobin is 18.2. Amylase and lipase are negative.
HOSPITAL COURSE: The patient was admitted and given intravenous fluids. GI consultation was called. The patient was given IV Reglan and Protonix. He was having nausea and vomiting and began to bring up frank blood. He was transferred to the ICU. He was hemodynamically stabilized. He was given transfusions as needed.
The patient was seen by GI doctor and had an upper endoscopy. He also had a surgical evaluation. The upper endoscopy showed that he has gastroesophageal reflux, esophagitis, esophageal ulcers. No active bleeding was seen. He was to continue Reglan and p.o. feedings. He was on oral Sudafed as well as midodrine for his blood pressure, which was hypotensive and always hypotensive. He was stabilized, doing better, GI bleed abated, and he was sent home. He will be taking Protonix and Reglan, as well as a seven-day course of Diflucan 100 mg p.o. daily.
