Summary Essay
Writing of medical reports is an art that any budding medical doctor ought to develop. This is because reports form the basis of communication as it gives as a summary of particular cases. Examples of medical reports include pathology reports in a postmortem case, surgical reports in cases of surgery, gynecological reports, and hematological reports, among others. Here is a summary of four select medical reports appraising their usefulness while at the same time pointing out aspects that can be improved.
The radiology report presented is for Marietta Mosley who presented with a history of left hip pain. Subsequently the admitting physician Dr John Youngblood made a primary diagnosis of a fractured left hip and thus requested a left hip radiographic image to confirm this. The radiograph was taken by Dr Neil Nofsinger who reported having identified an orthopedic device through the left femoral neck which appeared to be well aligned anatomically. The radiograph also identified a radiolucent band at the level of the lesser trochanter near an orthopedic screw on the lateral aspect of the femoral neck giving an impression of non-union of fracture through the femur shaft near the level of the lesser trochanter with marginal sclerosis. Active callus deposition could be seen on the lateral aspect of the femoral shaft.
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The information presented in the report indicates special components of a radiological report that must include the patient identification details and date, the presenting complaint, and the requested imaging technique from the referring clinician. On the other hand, the radiologist has presented the investigational findings and their probable impression, which forms a good basis of how findings should be presented.
However, a summary of how the imaging technique was done, misses. This should be included as there are cases of fracture upon which images taken only from one angle are not sufficient for diagnostic purposes. Besides, the radiological report does not contain an advice section from the radiographer (European Society of Radiology, 2011) .
A pathology report is a description of tissue samples (biopsies) removed from the body by a pathologist for further analysis either macroscopically or microscopically. The report begins by giving the patients identification details by name and hospital number as Sumio Yukimura and 11449, respectively. Besides, details of the admitting physician and both a pre and perioperative diagnosis of cholelithiasis are provided. The type of specimen submitted has been identified as the gallbladder and stone on a container labeled "gallbladder". Timelines have also been given on when the sample was received and when it was reported. The report gives a gross description of the specimen as being 9 cm in length and 2 cm in diameter. The serosal surface had diffused fibrous adhesions while the mucosal surface was eroded. The lumen contained a large stone measuring 2 cm. A gross diagnosis of gallstone was made while the microscopic findings yielded gallbladder, chronic hemorrhagic cholecystitis with cholelithiasis.
The report shades more light on how the gross description of a specimen should be. However, the report could be improved in some aspects such as the type of procedure by which the specimen was obtained and a detailed description of what the pathologist visualized during the microscopic exam. This would go a long way in helping improve clinical care and population-wide health interventions when such report findings are cumulated over time (Bosman & Lehr, 2016) .
Next is a discharge summary which is a report given to all patients who leave a healthcare facility where they had been receiving treatment or any caregiving an account of their condition and care received while at the facility. The summary has the patient identification details, including the name, hospital number. Also, the date of admission and discharge and the dates when significant interventions such as splenectomy surgery, blood transfusions, and laboratory investigations were done are given. The name of the doctors who handled the patient is also given. The report presents a brief history of the patient, laboratory data, and hospital course and discharges instructions, including medications.
The report shades light into the importance of having clear laboratory findings recorded as they could be used as a point of reference in assessing the wellbeing of the patient as evidenced by monitoring of the platelet indices for the patient that facilitated several platelet transfusions.
An area for improvement in the discharge summary lies in including a segment labelled explicitly as the patient's condition on discharge, including overall condition, physical exam findings, and laboratory findings at discharge. Such information is critical in this age of medico-legal medicine. Besides, a section for home support or what to do in case symptoms return before the date of appointment needs to be included as this will improve healthcare follow-ups (Horwitz, Jeng, Brewster, & Krumholz, 2013) .
The last report is an operative report which has been described as one that gives a full description of a surgical procedure performed on a patient. The operative report given is one of a total abdominal hysterectomy with Marshall-Marchetti correction done on a client who had a preoperative diagnosis of urinary incontinence secondary to cystourethrocele. The admitting doctor and the name of the surgeons who did the operation have been indicated. The report also indicates the date of surgery and the type of anesthesia type used.
The report forms a template upon which a budding surgeon can use to improve their report writing skills as it lays down the simple rule that the details of the procedure done have to be included in the report. Besides, the date of surgery is paramount in addition to specifying the type of anesthesia used.
A significant omission in so far as the report is concerned is a lack of identification of the scrub nurse and the anesthesiologist. This is because these two professionals are significant stakeholders in the performance of any surgical procedure. The surgery cannot take place without the anesthesia being administered and incase of any anesthetic complications; it is the anesthesiologist that is required to handle. For the part of the nurse, they are in most cases, the custodians of the surgical equipment, scrubs, and other utilities to be used during operations. Besides the theatre or scrub nurse receive a patient into theatre and documents vital signs.
Besides, for continuity of care to happen, an operative note ought to specify the post-operative management measures. This may include things such as when to initiate feeding, dressing changes, and any medications (Hoggett, Wright, & Wilson, 2017) .
In conclusion, various kinds of medical report summaries exist. It is thus essential that any medical practitioner familiarizes oneself with such format for ease of communication and understanding with other specialities of medicine. Besides, although the formats presented capture most of the details needed, a few aspects need to be included to keep up with the realities of 21st-century medicine.
Sample Reports
2a. Sample Radiology Report
According to the left hip X-Ray imaging, the patient has a broken left hip. The patient had complained of pain on the left hip with no history of reactions to substances such as medications, food, or other environmental objects. A fracture is a medical term for any breakage in any bone.
The image also revealed the existence of a special metallic corrective bone device on the neck of the thigh bone. However, there is no old film of the same body region to compare. The good thing is that the left thigh bone neck region is in the shape and position that it is usually supposed to be in. On the special corrective bone device, there is a screw that is on the outer side of the thigh bone neck. This screw goes closer to an outgrowth at the junction on the lower inner part of the neck of the thigh bone and the upper inner part of the thigh bone. It is here where it appears there is a bone break that failed to unite. This is because this point has shown to be transparent to the x-ray imaging done. However, the age of the bone break is difficult to tell. The point appears to be abnormally hardened on both sides at the margins. The point also seems to have a slight bend. On the outer part of the thigh bone shaft, there are signs of new bone-forming in a lively manner (Oberg & Villemaire, 2018) .
With the above findings, the probable issue maybe the existence of breakage in the bone that cuts across the region just below the neck of the thigh bone on the inner aspect on the upper part of the thigh bone shaft to unite. There is no apparent detrimental displacement at the neck of the thigh bone.
2b. Sample Pathology Report
A preoperative diagnosis means the tentative condition that one is thought to have before being operated on while a post-operative diagnosis means the condition that one is deemed to have the following findings at the time of operation. The condition has been identified as cholelithiasis both before and after surgery. This is the existence of small hardened substances in a small organ found below the liver called a gallbladder.
The gross description refers to the description of the sample collected in general appearance as seen by the naked eye. The specimen is the medical term for the sample taken. In this case, the sample container was labeled, "gallbladder". It consisted of the gallbladder whose longest side measured 2 centimetres whiles its measurement from side to side through the centre, which is diameter, was 2 centimetres. The serosa, which refers to the membrane covering the outer surface of the organ showed widespread fibre like adhering of tissues on the organ. The wall of the gallbladder was abnormally thick and showed signs of bleeding. On the other hand, the mucosa, which is the inner layer of the organ, was eroded. Inside the organ there existed one large stone whose diameter was 2 cm. Representative parts from the organ were taken and stored in a cassette which a specially made plate is containing the sample structure that can be easily moved and stored for future use.
The overall condition from the visual analysis of the sample was gallstone which refers to the existence of a hardened substance made of deposits such as calcium inside the gallbladder. After an analysis over the microscope for finer details, the condition found was gallstones, chronic hemorrhagic cholecystitis with cholelithiasis.in simple terms the gallbladder contains gallbladder stones that have led to bleeding and long-term injury on the layers of the gallbladder.
2c. Sample Discharge Report
Reason for admittance and history of present illness
The 21-year-old patient was admitted to undergo a scheduled operation known as splenectomy. Splenectomy is an operation that entails the removal of the organ spleen by a surgeon who is a doctor specifically trained to do operations. The spleen is an organ located on the upper left abdomen just on the left of the stomach whose main role is that of a blood filter. The operation was necessitated because of a failure to respond to medications given. The cause of the illness that necessitated the surgery is idiopathic thrombocytopenic purpura (ITP) and systemic lupus erythematosus (SLE). Thrombocytopenic purpura is a condition that is characterized by a decrease in the blood cells responsible for blood clotting mechanisms. Blood clotting is the body response to stop bleeding, such as in the case where one has a bleeding cut. This is achieved through the action of platelets, a component of blood cells. The specific kind of problem was idiopathic meaning its cause is not known. However, splenectomy was preferred as in most cases, destruction of the cells responsible for bleeding happens in the spleen; hence its removal would bring a remedy. On the other hand, SLE as a medical condition usually has long term mild and severe phases that are a result of the body's immune cells attacking self. Its main symptoms include generalized body pains and weaknesses that are on and off, increased frequency of bleeding and bruising as seen in the white woman since last year June.
Laboratory data
The patient had several laboratory tests done. The chest imaging showed normal lungs and no identifiable abnormality in the chest region. The heart electrical activity, the electrocardiogram, was also normal. The electrical activity of the heart implies the transmission of the signals that are generated when the heart beats through the parts of the heart. Assessment of the urine sample, urinalysis was normal showing no signs of infection or damage to the kidney. The electrolyte levels were al normal. On the blood count aspect, the red blood cell measurements were all within normal values while the white blood cell levels were slightly increased, unlike the platelet cell counts, which were decreased. Red blood cells are the cells responsible for transporting oxygen in the body, while white blood cells are the cells charged with fighting infections. If increased, they show the existence of an infection. The low platelet levels accounted for the bruising experienced.
During the hospital stay, the patient underwent an operation on the 19th of February. The patient underwent the addition of platelets to their body system two times as they were low. The period after surgery had no undesired outcomes as the wound healed well.
Discharge medications were also given to be used at home. These included taking prednisolone 20mg four times a day. Prednisolone is a drug that regulates the body's immune system to stop it from damaging its cells and tissues. The pain medication Percocet was also given for relief of pain where the patient was to take 1 to 2 tablets every four hours if needed. The drug is a combination of paracetamol and oxycodone, which are both pain killers. Lastly, the patient was put on a multivitamin, where one was to be taken each day in the morning. Multivitamins are a combination of vitamins that help in the body immune and generally are needed for a healthy life as they improve the nutritional status of an individual.
Follow up instructions entailed the patient visiting the surgeon and another doctor who is a hematologist and thus has special training in dealing with blood conditions hence better placed to handle the ITP and SLE. The two conditions formed the diagnosis at the time of going home from the hospital.
2d. Sample Operative Report
Before undergoing the operation, the patient's condition was referred to as urinary incontinence secondary to cytourethrocele, which was also the diagnosis after surgery. This is a condition which means the reason a patient has problems controlling the passage of urine is because of the existence of a direct connection from the bladder or urine bag to the urethra which is the tube connection between the bladder and the outside of the body; that facilitates passage of urine. The direct connection is an abnormal development because special mechanisms at the bladder usually control the flow of urine out of the bladder to the urethra –urethra junction called the sphincter.
The operation done consisted of removal of the uterus, which is the womb and the cervix, which is the neck of the womb. Access to the womb was through the abdomen. This is what was referred to as abdominal hysterectomy, where the womb was accessed and removed through the abdomen. Besides, a special operation, the Marshall-Marchetti correction was done. In this procedure, urinary incontinence is corrected through having a surgeon suspend the region between the urine bag and urethra or the bladder neck on the pubic bone. The bone is the one found in the groin region. For this purpose, three special threads called catgut sutures had to be used. Special tubes for draining any accumulating fluid were then put in place. Other steps included the cutting of some tissues to access the bladder and urethra clearly while at the same time controlling any bleeding blood vessels.
The operation was done with the patient in a deep sleep-like state called general endotracheal anesthesia. With this, the patient was unconscious and could not feel any pain until after the procedure when they could be woken up through reversing the anesthesia.
References
Bosman, F. T., & Lehr, H.-A. (2016). Quality in pathology: how good is good? An introduction. Virchows Archives, European Journal of Pathology , 468. Retrieved from https://link.springer.com/article/10.1007/s00428-015-1896-3
European Society of Radiology. (2011). Good practice for radiological reporting. Guidelines from the European Society of Radiology (ESR). Insights into Imaging . Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259387/
Hoggett, L., Wright, A., & Wilson, J. (2017). How to write an operation note. The British Medical Journal .
Horwitz, L., Jeng, G., Brewster, U., & Krumholz, H. (2013). Comprehensive quality of discharge summaries at an academic medical centre. Journal of Hospital Medicine . Retrieved 2020, from https://www.journalofhospitalmedicine.com/jhospmed/article/127028/discharge-summary-quality
Oberg, D. V., & Villemaire, L. (2018). Grammar and Writing Skills for the Health Professional (3rd ed.). Cengage Learning.
