Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Head & Neck Cancer Consult

Description: Newly diagnosed head and neck cancer. The patient was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa.
(Medical Transcription Sample Report)

REASON FOR CONSULTATION: Newly diagnosed head and neck cancer.

HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 61-year-old gentleman who was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa. He was also noted to have palpable level 2 cervical lymph nodes. His staging is T3 N2c M0 Stage IV invasive squamous cell carcinoma of the head and neck. The patient comes in to the clinic today after radiation Oncology consultation. His Otolaryngologist performed a direct laryngoscopy with biopsy on July 29, 2010. The patient reports that in December-January timeframe, he had noted some difficulty swallowing and ear pain. He had a work up by his local physician that was relatively negative, and he was treated for gastroesophageal reflux disease. His symptoms continued to progress, and he developed difficulty with his speech, dysphagia, otalgia and odynophagia. He was then referred to Dr. X and examination revealed a mass at the right base of the tongue that extended across the midline to include the left base of the tongue as well as posterior extension involved in the right tonsillar fossa. He was noted to have bilateral neck nodes. His biopsy was positive for squamous cell carcinoma.

PAST MEDICAL HISTORY: Significant for mild hypertension. He has had cataract surgery, gastroesophageal reflux disease and a history of biceps tendon tear.

ALLERGIES: Penicillin.

CURRENT MEDICATIONS: Lisinopril/hydrochlorothiazide 20/25 mg q.d., alprazolam 0.5 mg q.d., omeprazole 20 mg b.i.d., Lortab 7.5/500 mg q 4h p.r.n.

FAMILY HISTORY: Significant for father who has stroke and grandfather with lung cancer.

SOCIAL HISTORY: The patient is married but has been separated from his wife for many years, they remain close, and they have two adult sons. He is retired from the Air Force, currently works for Lockheed Martin. He was born and raised in New York. He does have a smoking history, about a 20 pack-year history and he reports quitting on July 27. He does drink alcohol socially. No use of illicit drugs.

REVIEW OF SYSTEMS: The patient's chief complaint is fatigue. He has difficulty swallowing and dysphagia. He is responding well to Lortab and Tylenol for pain control. He denies any chest pain, shortness of breath, fevers, chills and night sweats. The rest of his review of systems is negative.

PHYSICAL EXAM:
VITALS: BP: 115/70. HEART RATE: 62. TEMP: 97.4. Weight: 93.6 kg.
GEN: He is very pleasant and in no acute distress. He has noticeable mass on his left neck.
HEENT: Pupils are equal, round, and reactive to light. Sclerae anicteric. His oropharynx is notable for scalloped tongue and he has no oral ulcers. Upon protrusion of his tongue, he has deviation to the right.
NECK: Noticeable for bilateral palpable adenopathy with a large palpable mass in the left neck.
LUNGS: Clear to auscultation on the right. He has some mild vesicular breath sounds in the left.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Soft. He has positive bowel sounds. No hepatosplenomegaly. No axillary inguinal adenopathy.
EXT: No lower extremity edema.

LABORATORY STUDIES:
1. A PET/CT scan shows a large hypermetabolic mass involved in the posterior aspect of the tongue, which is predominantly right-sided but extends across the midline to involve the right posterior aspect of the tongue as well.
2. Extensive bulky hypermetabolic cervical lymphadenopathy bilaterally.
3. No evidence of distant hypermetabolic metastatic disease.
4. His biopsy of the right base of the tongue, invasive squamous cell carcinoma. Biopsy of the left base of the tongue, invasive squamous cell carcinoma moderately differentiated.

ASSESSMENT/PLAN: This is a pleasant but unfortunate 61-year-old gentleman who was diagnosed with stage IV, a squamous cell carcinoma of the oropharynx. He has met with radiation oncology to discuss the plan and he has also been in close contact with his dentist. He has a known abscess and is in need of some bridge work. I discussed issues with his dentist and the patient will be seeing this Friday for cleaning. One of the things that we will need to coordinate is evaluation of the involvement of his salivary glands. There needs to be a discussion as to whether or not he would be better off with the tooth extraction prior to radiation. We will coordinate this between myself, radiation oncology, and his dentist.

As far as his chemotherapy treatment, the plan at this point is to proceed with two cycles of induction chemotherapy. The first cycle will include docetaxel, cisplatin and 5-fluorouracil plus Erbitux. Typical administration is docetaxel, cisplatin and 5-fluorouracil on day 1 with continuous infusion of 5-fluorouracil through day 4. Erbitux will be administered on day 1 and day 8 of the first cycle. We will plan to proceed with the second cycle to include docetaxel, cisplatin and continuous infusion of 5-fluorouracil without the Erbitux. Following induction chemotherapy, we plan to obtain a PET/CT scan. Again, this will be closely coordinated with radiation onset if they can do with planning CT at that time of the PET. Radiation will be planned with concurrent Erbitux. This will be given, the first dose will be one week prior to starting the radiation and then given weekly throughout radiation. I did discuss briefly with the patient the possibility of admission for the induction chemotherapy. The patient was not very excited at this particular discussion. Otherwise, I do feel with him living in the Longmont area that this may be our best bet and would also be a way of being able to closely monitor his kidney function and administer the necessary hydration. He is scheduled for chemo education on August 16. He received prescription refill for Lortab for pain management, and I will see him in clinic when he comes in for chemotherapy education so that we can talk further about treatment administration. I appreciate the consultation.

Keywords: consult - history and phy., neck cancer, carcinoma, t3 n2c m0, squamous cell carcinoma, tonsillar fossa, neck, oncology, tongue, head, fluorouracil, erbitux, chemotherapy, cancer, radiation, squamous,
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