Hospital discharge report and main types of reports used by radiologists and pathologists

Discussion Question 1 

Summary 

The (n) patient, a 60-year old (n) woman, was admitted because of respiratory distress. A comprehensive clinical examination of (pn) her condition indicated the need for intubation. (pn)Her medical history is characterized by two (n) myocardial infarctions in 2000 and 2007. In the recent past, the (n) patient had been hospitalized on two different occasions because of (n) pneumonia as a result of (a) streptococcal (n) infection and on another occasion because of (a) abdominal pains among other symptoms which upon examination a (a) gastrointestinal (n) infection was diagnosed. In addition, the patient has a history of (a) peptic (n) ulcer . It was also identified that she had high blood pressure and had stopped using her (a) antidiuretic drugs. (pn) She also has a history of respiratory failure. She was apprehensive of another myocardial infarction but her pathological symptoms did not indicate a myocardial infarction. The patient is an (a) excessive smoker and has been smoking for the last twelve years. On the day of admission, she denied (a) thoracic (n) pain while trying to breathe. However, she reported pain in the (a) superficial (n) muscles. 

Hospital Course 

The patient was hospitalized and intubated. (a) Intravenous antibiotic and diuretic was administered. A short period after intubation, (pn) she developed (a) pleural effusion. In addition, the (n) patient received (n) treatment for bronchial dilation. Steroid therapy was also administered through intra muscular injection. (pn) Her course was characterized by a gradual improvement. After four days, (pn) she was extubated. In the course of her hospitalization, (pn) it was identified that (pn) she had developed an (n) inguinal hernia. An inguinal hernia can be as a result of muscle weakness causeHd by (n) coughs that accompany smoking (Mosby, 2013). On the day when (pn) she was discharged, (pn) she had less (n) wheezes, a regular heart rate, (a)soft (n)abdomen, and no (a) distended (n) veins around the neck area. The patient was stable and could be managed on an outpatient basis. 

Discussion Question 2 

There are other different medical reports written by different specialists in the medical filed. Radiologists for example write radiology and imaging reports. A radiology and imaging reports provides the interpretation of a radiologist on a specific procedure. Radiology reports are usually done within a period of four to eight hours after the procedure is done ( Oberg & Villemaire, 2017 ). Such procedures include x-rays, magnetic resonance imaging, and nuclear medicine among others ( Oberg & Villemaire, 2017 ). Such procedures generate visual images that help in making diagnosis. Pathology reports are written by pathologists who examine tissue samples and develop a report on their findings. This type of report provides a description of tissue samples that have been extracted from a body ( Oberg & Villemaire, 2017 ). 

Pathology reports provide both macroscopic and microscopic results. Macroscopic outcomes provide a description of physical observation using the naked eye. Such descriptions include color and size among other physical aspects. In contrast, microscopic results describe tissue appearance as observed under a microscope. The end result of the findings recorded in a pathology report is diagnosis or impression ( Oberg & Villemaire, 2017 ). A pathology report is usually completed within a period of twenty-four hours after reception of laboratory findings. The other type of medical report is an operative report written by surgeons. The reports gives a detailed description of conducted surgical procedures on patients ( Oberg & Villemaire, 2017 ). The information found in an operative report include experiences before, during, and after operation. Pathological information, diagnosis, the anesthesia used, and the nature of the surgical procedure performed are all indicated in an operative report (). The information provided in an operative report end with the patient being transferred into the recovery unit. 

References 

Mosby. (2013).  Mosby's Medical Dictionary - E-Book . Elsevier Health Sciences. 

Oberg, D., & Villemaire, L. (2017). Grammar and Writing Skills for the Health Professional (3rd ed.). Boston , MA: Cengage Learning.