Sample Type / Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Prostate Adenocarcinoma - 3
Moderately differentiated adenocarcinoma, 1+ enlarged prostate with normal seminal vesicles.
(Medical Transcription Sample Report)
The patient is a 63-year-old executive who was seen by his physician for a company physical. He stated that he was in excellent health and led an active life. His physical examination was normal for a man of his age. Chest x-ray and chemical screening blood work were within normal limits. His PSA was elevated.IMAGING:
Chest x-ray: Normal.
CT scan of abdomen and pelvis: No abnormalities.LABORATORY:
Ultrasound guided sextant biopsy of prostate: Digital rectal exam performed at the time of the biopsy showed a 1+ enlarged prostate with normal seminal vesicles.PATHOLOGY:
Prostate biopsy: Left apex: adenocarcinoma, moderately differentiated, Gleason's score 3 + 4 = 7/10. Maximum linear extent in apex of tumor was 6 mm. Left mid region prostate: moderately differentiated adenocarcinoma, Gleason's 3 + 2 = 5/10. Left base, right apex, and right mid-region and right base: negative for carcinoma.TREATMENT:
The patient opted for low dose rate interstitial prostatic implants of I-125. It was performed as an outpatient on 8/10.
soap / chart / progress notes, sextant biopsy, vesicles, seminal, apex, interstitial prostatic implants, moderately differentiated adenocarcinoma, normal seminal vesicles, enlarged prostate, gleason's, moderately, differentiated, prostate, adenocarcinoma,
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