Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Gastroenterology
Sample Name: Cholangiocarcinoma Consult

Description: Newly diagnosed cholangiocarcinoma. The patient is noted to have an increase in her liver function tests on routine blood work. Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis.
(Medical Transcription Sample Report)

REASON FOR CONSULTATION: Newly diagnosed cholangiocarcinoma.

HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 77-year-old female who is noted to have an increase in her liver function tests on routine blood work in December 2009. Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis. Common bile duct was noted to be 10 mm in size on that ultrasound. She then underwent a CT scan of the abdomen in July 2010, which showed intrahepatic ductal dilatation with the common bile duct size being 12.7 mm. She then underwent an MRI MRCP, which was notable for stricture of the distal common bile duct. She was then referred to gastroenterology and underwent an ERCP. On August 24, 2010, she underwent the endoscopic retrograde cholangiopancreatography. She was noted to have a stricturing mass of the mid-to-proximal common bile duct consistent with cholangiocarcinoma. A temporary biliary stent was placed across the biliary stricture. Blood work was obtained during the hospitalization. She was also noted to have an elevated CA99. She comes in to clinic today for initial Medical Oncology consultation. After she sees me this morning, she has a follow-up consultation with a surgeon.

PAST MEDICAL HISTORY: Significant for hypertension and hyperlipidemia. In July, she had eye surgery on her left eye for a muscle repair. Other surgeries include left ankle surgery for a fractured ankle in 2000.

CURRENT MEDICATIONS: Diovan 80/12.5 mg daily, Lipitor 10 mg daily, Lutein 20 mg daily, folic acid 0.8 mg daily and multivitamin daily.

ALLERGIES: No known drug allergies.

FAMILY HISTORY: Notable for heart disease. She had three brothers that died of complications from open heart surgery. Her parents and brothers all had hypertension. Her younger brother died at the age of 18 of infection from a butcher's shop. He was cutting Argentinean beef and contracted an infection and died within 24 hours. She has one brother that is living who has angina and a sister who is 84 with dementia. She has two adult sons who are in good health.

SOCIAL HISTORY: The patient has been married to her second husband for the past ten years. Her first husband died in 1995. She does not have a smoking history and does not drink alcohol.

REVIEW OF SYSTEMS: The patient reports a change in her bowels ever since she had the stent placed. She has noted some weight loss, but she notes that that is due to not eating very well. She has had some mild fatigue, but prior to her diagnosis she had absolutely no symptoms. As mentioned above, she was noted to have abnormal alkaline phosphatase and total bilirubin, AST and ALT, which prompted the followup. She has had some difficulty with her vision that has improved with her recent surgical procedure. She denies any fevers, chills, night sweats. She has had loose stools. The rest of her review of systems is negative.

PHYSICAL EXAM:
VITALS: BP: 108/60. HEART RATE: 80. TEMP: 98.5. Weight: 75 kg.
GEN: She is a very pleasant female, in no acute distress.
HEENT: She has obvious strabismus of the left eye with medial deviation. Her pupils are equal, round, and reactive to light. Oropharynx is clear.
NECK: Supple. She has no cervical or supraclavicular adenopathy.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Soft, nontender, and nondistended. No palpable masses. No hepatosplenomegaly.
EXT: Lower extremities are without edema.

LABORATORY STUDIES: Sodium 141, glucose 111, total bilirubin 2.3, alkaline phosphatase 941, AST 161, and ALT 220. White blood cell count 4.3, hemoglobin 11.6, hematocrit 35, and platelets 156,000. Total bilirubin from August 25, 2010 was 1.6, alkaline phosphatase 735, AST 123, ALT 184, CA99 is 109. Bile duct brushings are notable for atypical cell clusters present, highly suspicious for carcinoma.

ASSESSMENT/PLAN: This is a very pleasant 77-year-old female who has findings suspicious for a cholangiocarcinoma. The patient was referred to our office to discuss this diagnosis. I spent greater than an hour with the patient and her husband discussing this potential diagnosis, reviewing the anatomy and answering questions. She is yet to have a surgical consultation, and we discussed the difficulty that we sometimes have with patients meeting surgical criteria to manage cholangiocarcinoma. The patient also had questions about the Medical University and possibly seeking a second opinion. She will contact our office after her surgical consultation if she needs assistance with obtaining a second opinion. We also talked about our clinical research program here. Currently, we do have a Phase II Study for advanced gallbladder carcinoma or cholangiocarcinoma for patients that are unresectable. We will go ahead and provide her with a consent form so that she can look that over and it will give her some more information about the malignancy and treatment approaches. We will schedule her for followup in three weeks. We will also schedule her for PET/CT scan for staging.

Keywords: gastroenterology, liver function tests, gallbladder, sludge, adenomyomatosis, intrahepatic ductal dilatation, bile duct, ercp, mrcp, cholangiopancreatography, common bile duct, oropharynx, cholangiocarcinoma,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples