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Convert the below dictated lines into Discharge Summary transcription with appropriate format
of chart note including headings and all the rules of chart note transcription
admitting diagnosis abdominal pain
discharge diagnosis appendicitis status post appendectomy
history of present illness this is the sixty five year old female who presents in the emergency
room with abdominal pain nausea and vomiting
all of it started approximately two week ago
past medical history diabetes hypertension history of ovarian cysts and recurrent urinary tract
infection(UTI)
past surgical history past hysterectomy approximately thirty year ago prolapse bladder repair
with mesh
allergies betadine
home medications avandia metformin quinapril and tricor
her initial lab work in the emergency room shows the wbc sixteen point one
hemoglobin thirteen point five and hematocrit thirty nine point five
urinalysis is negative
her cat scan shows a thickened appendix and terminal ileum set stranding
vital signs patient has a fever with the temperature ninety six point eight
vital signs are stable
patient was admitted and given IV food and IV antibiotics
an arrangement was made to take the patient to the operating room
patient underwent an appendectomy
she tolerated the procedure well
intraoperative finding so hopefully the appendix with purulent drainage
patient was taken to PACU in stable condition
post operative course day one and two patient did complain of nausea and vomiting
day four patient was tolerating a regular diet
her pain was managed with po medication
her abdominal pain shows a positive bowel sound
she has minimal tenderness near the quarter of incision
the incision itself has been packed open
the edges are without erythema
the patient will continue to have wound care at home and she has a follow up within a week

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Convert the below dictated lines into Discharge Summary transcription.docx

  • 1. Convert the below dictated lines into Discharge Summary transcription with appropriate format of chart note including headings and all the rules of chart note transcription admitting diagnosis abdominal pain discharge diagnosis appendicitis status post appendectomy history of present illness this is the sixty five year old female who presents in the emergency room with abdominal pain nausea and vomiting all of it started approximately two week ago past medical history diabetes hypertension history of ovarian cysts and recurrent urinary tract infection(UTI) past surgical history past hysterectomy approximately thirty year ago prolapse bladder repair with mesh allergies betadine home medications avandia metformin quinapril and tricor her initial lab work in the emergency room shows the wbc sixteen point one hemoglobin thirteen point five and hematocrit thirty nine point five urinalysis is negative her cat scan shows a thickened appendix and terminal ileum set stranding vital signs patient has a fever with the temperature ninety six point eight vital signs are stable patient was admitted and given IV food and IV antibiotics an arrangement was made to take the patient to the operating room patient underwent an appendectomy she tolerated the procedure well intraoperative finding so hopefully the appendix with purulent drainage
  • 2. patient was taken to PACU in stable condition post operative course day one and two patient did complain of nausea and vomiting day four patient was tolerating a regular diet her pain was managed with po medication her abdominal pain shows a positive bowel sound she has minimal tenderness near the quarter of incision the incision itself has been packed open the edges are without erythema the patient will continue to have wound care at home and she has a follow up within a week