Discharge Summary Report Sample:

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ADMITTING DIAGNOSIS:  Torn medial meniscus of left knee.

HOSPITAL COURSE:  This 52-year-old male with a work related injury to his left knee and failure to improve on conservative therapy with MRI scan indicating oblique tearing of the posterior horn of the medial meniscus of the left knee was admitted at this time for diagnostic operative arthroscopic surgery.  The patient underwent routine preadmission testing and was cleared for surgery.   He was taken to the Operating Room on the date of admission and, under general anesthesia underwent resection of a torn posterior horn of his medial meniscus with chondroplasty of the anterior surface of the medial femoral condyle for grade III chondromalacia and three compartmental synovectomy for hypertrophic synovitis.  Autogenous platelet gel fabricated from the patient’s own blood preoperatively was utilized to facilitate soft tissue healing.

DISPOSITION:  The patient tolerated the surgical procedure well.  Upon recovering from his anesthesia, he was allowed to ambulate with a bulky Jones dressing and extension knee brace.

CONDITION ON DISCHARGE:  He was discharged home ambulating with crutches and weight bearing as tolerated.      

FOLLOW-UP:  The patient was discharged with instructions to return to see me in my office in 24 hours time for dressing removal and wound follow up care.

DISCHARGE MEDICATIONS:  The patient was discharged home taking Darvocet-N 100 for pain and Omnicef 300 mg one tablet twice daily as a prophylaxis against infection.