Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Prostate Adenocarcinoma - 3

Description: Moderately differentiated adenocarcinoma, 1+ enlarged prostate with normal seminal vesicles.
(Medical Transcription Sample Report)

PHYSICAL EXAMINATION: 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: PSA 14.6.

PROCEDURES: 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.

Keywords: 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,
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