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: Prostate Adenocarcinoma - H&P

Description: Adenocarcinoma of the prostate, Erectile dysfunction - History & Physical
(Medical Transcription Sample Report)

HISTORY OF PRESENT ILLNESS: The patient is a 62-year old male with a Gleason score 8 adenocarcinoma of the prostate involving the left and right lobes. He has a PSA of 3.1, with a prostate gland size of 41 grams. This was initially found on rectal examination with a nodule on the right side of the prostate, showing enlargement relative to the left. He has undergone evaluation with a bone scan that showed a right parietal lesion uptake and was seen by Dr. XXX and ultimately underwent an open biopsy that was not malignant. Prior to this, he has also had a ProstaScint scan that was negative for any metastatic disease. Again, he is being admitted to undergo a radical prostatectomy, the risks, benefits, and alternatives of which have been discussed, including that of bleeding, and a blood transfusion.

PAST MEDICAL HISTORY: Coronary stenting. History of high blood pressure, as well. He has erectile dysfunction and has been treated with Viagra.

MEDICATIONS: Lisinopril, Aspirin, Zocor, and Prilosec.

ALLERGIES: Penicillin.

SOCIAL HISTORY: He is not a smoker. He does drink six beers a day.

REVIEW OF SYSTEMS: Remarkable for his high blood pressure and drug allergies, but otherwise unremarkable, except for some obstructive urinary symptoms, with an AUA score of 19.

PHYSICAL EXAMINATION:
HEENT: Examination unremarkable.
Breasts: Examination deferred.
Chest: Clear to auscultation.
Cardiac: Regular rate and rhythm.
Abdomen: Soft and nontender. He has no hernias.
Genitourinary: There is a normal-appearing phallus, prominence of the right side of prostate.
Extremities: Examination unremarkable.
Neurologic: Examination nonfocal.

IMPRESSION:
1. Adenocarcinoma of the prostate.
2. Erectile dysfunction.

PLAN: The patient will undergo a bilateral pelvic lymphadenectomy and radical retropubic prostatectomy. The risks, benefits, and alternatives of this have been discussed. He understands and asks that I proceed ahead. We also discussed bleeding and blood transfusions, and the risks, benefits and alternatives thereof.

Keywords: urology, gleason score, gleason, prostate gland, prostascint, retropubic prostatectomy, adenocarcinoma of the prostate, erectile dysfunction, adenocarcinoma, radical, prostatectomy, erectile, dysfunction, prostate,
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