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The patient also complains of weight loss of 25 pounds in the last 6 months. FOLLOWUP: Follow up with primary care physician in 1 week. CT of the brain showed no acute changes, left periorbital soft tissue swelling. DATE OF DISCHARGE: MM/DD/YYYY. No problem. The patient had AVR 6 years ago. A medical report is an updated detail of a medical examination of a certain patient. 3 tablets so a total of 90 mg q.a.m., citalopram 10 mg q.a.m., fluconazole 200 mg daily, azathioprine 100 mg daily, metoprolol 50 mg b.i.d. 3. FAMILY HISTORY: Positive for atherosclerosis, hypertension, autoimmune diseases in the family. Orthostatics were ordered. DTRs are normal. History of recurrent urinary tract infection. Vasovagal syncope, status post fall. Electrolytes were normal. She was given IV Dilaudid as needed. So simply pick which ones you think suits your preference and download, that simple! She has finished HBO at this time. Came to ER and had a CT head, which was within normal limits. Amlodipine was discontinued, metoprolol was decreased.

This template includes patient and doctor’s particulars, medical information, clinical history, findings, financial issues, welfare or property related information relevant to the payment, investigation results and diagnosis.

Glucose was 142. These templates are content-ready and are pre-formatted so that it’ll be easier for you. 8. 4. Recent history of hematochezia but believes it was secondary to proctitis and secondary to decreased appetite. Urine C&S showed no growth. Whether it’s a medical annual report or medical executive report, using these samples surely is advantageous.

She was seen by Dr. Doe who recommended TobraDex t.i.d. The patient was started on a taper of hydrocortisone. Creatinine was down to 1.2. It is our hope that we were able to cover as much of it, such as the tidbits about how to write a medical report for a patient. 2. Sodium 133, potassium 4.7, chloride 104. EOMI. MEDICATIONS: Zithromax for two remaining days, albuterol one dose nebulizer treatment q.i.d. The patient at home was on Digitalis. From the name itself, a medical report is a written report that usually contains the results of a medical examination conducted on a patient. 1. CT abdomen and pelvis showed prior cholecystectomy, diverticulosis of sigmoid colon, two benign-appearing simple cysts involving the right kidney, calcified arteriosclerotic plaque disease of the abdominal aorta and iliac vessels bilaterally.

Echocardiogram was normal, and when the patient was able, her orthostatic blood pressures were within normal limits. Blood urea nitrogen of 18 and creatinine of 1.1. Status asthmaticus: The patient was admitted to the pediatric intensive care unit in moderate to severe respiratory distress with continuous albuterol treatments, Atrovent treatments q.4 h., Decadron intravenously and empiric treatment of respiratory infection with azithromycin intravenously. BRIEF HISTORY:  The patient is an (XX)-year-old female with history of previous stroke; hypertension; COPD, stable; renal carcinoma; presenting after a fall and possible syncope. Hemoglobin was 10.2. Depression. HEART: Irregular rhythm. Moving on, we will now discuss the varied creation process of medical reports. BRIEF HISTORY: The patient is a (XX)-year-old white female with known history of asthma since infancy, possible environmental allergies, who presented with progressive wheezing and respiratory distress for the past two days. This will give them awareness and knowledge about certain medical conditions that may affect the employee’s ability in performing assigned tasks or activities. No shortness of breath. A medical report tends to be all-encompassing, complete with details of a patient’s illness and even prescriptions. q.h.s., and Remeron 15 mg p.o. 3. Hospitals and other medical institutions are no exceptions. Solu-Medrol was discontinued on MM/DD/YYYY. On MM/DD/YYYY, Foley catheter was discontinued. The creation of a medical report may dictate that you keep a separate but identical copy for yourself. Dr. Doe had scoped the jejunum and found copious mucus and mild colitis. The patient does have a history of previous falls, one of which resulted in a hip fracture. Regardless if there are negative findings, it should also be included. Rather than deal with things like sales reports and the like, those organizations are responsible for creating a medical report. On MM/DD/YYYY, chest x-ray showed satisfactory PICC position. 6. daily, Atrovent inhaler 2 puffs q.i.d., albuterol inhaler 2 puffs q.4-6 h. Our sample templates contain all of these essential guidelines, as well as our executive report templates. and Colace 100 mg p.o. daily, potassium chloride 40 mEq p.o. Of course, you don’t want to include irrelevant details to it. 3. Mild confusion. To create a medical report, all one has to do is follow the following steps: A medical report that comes off as vague is practically useless. medications per family’s report. Subtherapeutic INR, the patient’s relative target INR is 2-3. For it to be valid and useful, the medical professional writing it must go into detail. Just like with our project closure report templates that contain information needed for project closure reports. MEDICATIONS: Darvocet-N 100 one tablet p.o.

for 1 week. Doing so will help guide other professionals who may be assisting the patient with his or her treatment. On MM/DD/YYYY, hemoglobin was 10.8. Since a medical report is meant for the benefit of the patient, it pays not to utilize too much vague medical jargon. Information includes patient’s name, ward, hospital name, medical consultant, discharge summary, the reason for admission and medical diagnosis, and past medical history. The patient’s Coumadin was stopped and she was placed on Plavix due to bleeding.

On MM/DD/YYYY, renal ultrasound was negative. Medical Transcription Discharge Summary Sample Report # 3. Port-A-Cath Insertion Medical Transcription Sample Report. History of chronic obstructive pulmonary disease. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 188/74, pulse 62, respirations 18 and saturation of 98% on room air. To suffice, you can also consider using our project report templates. 1. The patient also had a head CT which showed atrophy with old ischemic changes. She will continue with hemodialysis as an outpatient. 3. She will continue with good pulmonary toilet. Atrial fibrillation. daily. The patient was seen by renovascular surgery and infectious disease. 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.

Myelin-associated glycoprotein was negative. Among the numerous inclusions would be: possible allergies, vaccinations, current medical evaluation, health issues, family or personal medical history, and more. Wound C&S grew light growth with MRSA and the patient was started on vancomycin. Bronchiolitis, empirically treated. Deep venous thrombosis. She has had physical therapy and recovered completely from that. No thyromegaly. It describes or outlines the findings of a medical professional, along with any suggestions for the patient’s treatment and recovery. HEENT: Conjunctivae are normal.

and she is on Ambien 10 mg at bedtime for sleep. The patient had been doing well on only p.r.n. The patient has an episode of hypotension, 84/48, on MM/DD/YYYY. CT of the maxillofacial area showed no facial bone fracture. 3.

9. Clean catch urine culture showed only mixed skin flora. On MM/DD/YYYY, hemoglobin was 9.2. She was continued with HBO which had been performed as an outpatient. Often times such as with Alzheimer’s disease, the patient is unable to accurately communicate their past and present medical situation so it essential to have a mechanism in place that does this for them. This website uses cookies to improve your experience. Follow up per skilled nursing facility until discharged to regular residence. She will be on dicyclomine 20 mg q.6 h., tizanidine 4 mg b.i.d., lidocaine patch to the lower back and left shoulder 12 hours on and 12 hours off, Wellbutrin XR 150 mg 2 tablets daily, trazodone 50 mg b.i.d., Cymbalta 30 mg q.a.m.
5. LUNGS: Clear to auscultation and percussion bilaterally. 1. His folate was 18.7 and his TSH was 1.98, free T4 of 1.38 and T4 level of 7.4, cortisol level of 15.4, which are within normal limits. With that said, use specific terms and provide particular comments and suggestions for the benefit of the report’s recipient. Are you curious enough to try and learn more? Temperature was as high as 102.4.

She has Crohn’s disease. The patient also had a head CT, which showed atrophy with old ischemic changes.

4. Hypothyroidism. The patient fell and injured her knees on MM/DD/YYYY. 6. Hypertension. Before discharge, she received asthma education and social counseling along with the family and was connected with social work to help provide a home nebulizer for use. and p.r.n. 1 Generate the Patient Visit Summary Report; 2 Select Options For the Patient Visit Summary; 3 Save or Print the Report. Peripheral arterial disease with hypertension, peripheral neuropathy, atherosclerosis, hemorrhoids, proctitis, CABG, and cholecystectomy. DIAGNOSTIC STUDIES:  All x-rays including left foot, right knee, left shoulder and cervical spine showed no acute fractures.

What Is a Medical Report? b.i.d., Cardura 2 mg p.o. Trachea is central. 5.1 Configure Which Office Contact Information Should Appear; 5.2 Configure Problem List Notes Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies.

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