Explaining a Discharge Summary Sheet
Medical Terminology
Section I
Assignment Reading:
I. AMBULATORY CARE FACE SHEET Admit Date: 7/8/20XX @ 20:22 Discharge Date/Time: 7/9/20XX @ 10:10 Sex: M Age: 47 Disposition: Home Admitting Diagnosis: Possible esophageal foreign body. Discharge Diagnosis: Esophageal foreign body. Procedures: EGD with foreign body removal. CONSULTATION Date of Consultation: 7/8/20XX This is a 47-year-old male who was in his usual state of health until early this evening when he developed an acute episode of odynophagia and a sensation of a foreign body in the proximal esophagus. This occurred after the patient had several bites of fish. The patient was evaluated with C-spine films and soft-tissue films, but no definite foreign body was seen. The soft tissue was noted to be normal. The patient, however, continued to have a sensation of a foreign body in the proximal esophagus and was complaining of upper esophageal pain. He has no past history of dysphagia, tobacco abuse, peptic ulcer disease, or reflux history. The patient has no past history of lye or corrosive substance ingestion. He denies any fever, chills, or shortness of breath.
Past Medical History: Allergies: No known drug allergies. Medications: None. Surgeries: Repair of a laceration to the forehead 10 months ago. Medical History: History of hepatitis. Family History: Noncontributory. Review of Systems: No medical abnormalities. Physical Examination: Vital Signs: BP 130/80, P 92, T 98.5 General: This is a well-developed and well-nourished anxious black male in mild distress. Head and neck are normocephalic, atraumatic. Sclerae clear. The oropharynx is clear. The neck is supple with free range of motion and no thyromegaly. The trachea is midline and mobile. There is no crepitus noted. Lungs are clear
Section I
Assignment Reading:
I. AMBULATORY CARE FACE SHEET Admit Date: 7/8/20XX @ 20:22 Discharge Date/Time: 7/9/20XX @ 10:10 Sex: M Age: 47 Disposition: Home Admitting Diagnosis: Possible esophageal foreign body. Discharge Diagnosis: Esophageal foreign body. Procedures: EGD with foreign body removal. CONSULTATION Date of Consultation: 7/8/20XX This is a 47-year-old male who was in his usual state of health until early this evening when he developed an acute episode of odynophagia and a sensation of a foreign body in the proximal esophagus. This occurred after the patient had several bites of fish. The patient was evaluated with C-spine films and soft-tissue films, but no definite foreign body was seen. The soft tissue was noted to be normal. The patient, however, continued to have a sensation of a foreign body in the proximal esophagus and was complaining of upper esophageal pain. He has no past history of dysphagia, tobacco abuse, peptic ulcer disease, or reflux history. The patient has no past history of lye or corrosive substance ingestion. He denies any fever, chills, or shortness of breath.
Past Medical History: Allergies: No known drug allergies. Medications: None. Surgeries: Repair of a laceration to the forehead 10 months ago. Medical History: History of hepatitis. Family History: Noncontributory. Review of Systems: No medical abnormalities. Physical Examination: Vital Signs: BP 130/80, P 92, T 98.5 General: This is a well-developed and well-nourished anxious black male in mild distress. Head and neck are normocephalic, atraumatic. Sclerae clear. The oropharynx is clear. The neck is supple with free range of motion and no thyromegaly. The trachea is midline and mobile. There is no crepitus noted. Lungs are clear