Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Urology
Sample Name: Bladder Tumor

Description: Recurrent bladder tumor. The patient on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice.
(Medical Transcription Sample Report)

CHIEF COMPLAINT: Recurrent bladder tumor.

HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old woman, the patient of Dr. X, who on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice. The patient underwent TUR of several transitional cell carcinomas of the bladder on the bladder neck in 2006. This was followed by bladder instillation of BCG. At this time, the patient denies any voiding symptoms or hematuria. The patient opting for TUR and electrofulguration of the recurrent tumors.

ALLERGIES: None known.

MEDICATIONS: Atenolol 5 mg daily.

OPERATIONS: Status post bilateral knee replacements and status post TUR of bladder tumors.

REVIEW OF SYSTEMS: Other than some mild hypertension, the patient is in very, very good health. No history of diabetes, shortness of breath or chest pain.

PHYSICAL EXAMINATION: Well-developed and well-nourished woman, alert and oriented. Her lungs are clear. Heart, regular sinus rhythm. Back, no CVA tenderness. Abdomen, soft and nontender. No palpable masses.

IMPRESSION: Recurrent bladder tumors.

PLAN: The patient to have CBC, chem-6, PT, PTT, EKG, and chest x-ray beforehand.

Keywords: urology, bladder neck, voiding symptoms, hematuria, transitional cell carcinomas, ureteric orifice, bladder tumor, bladder, cystoscopy, papillomatosis, transitional, carcinomas, orifice,
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