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: Glioma - Consult

Description: Progressive low-grade glioma, now more than 20 years since initially diagnosed. She is status post craniotomy for debulking and has done well with the surgery.
(Medical Transcription Sample Report)

REASON FOR CONSULTATION: Glioma.

HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old woman who was initially diagnosed with a brain tumor in 1982. She underwent radiation therapy for this, although craniotomy was not successful for a biopsy because of seizure activity during the surgery. She did well for the next 10 years or so, and developed Parkinson disease, possibly related to radiation therapy. She has been followed by neurology, Dr. Z, to treat seizure activity. She has a vagal stimulator in place to help control her seizure activity.

Over the last few months, she has had increasing weakness on the right side. She has been living in a nursing home. She has not been able to walk, and she has not been able to write for the past three to four years.

MRI scan done on 11/13/2006 showed increase in size of the abdominal area and the left parietal region. There was slight enhancement and appearance was consistent with a medium- to low-grade tumor anterior to the motor cortex.

Surgery was performed during this admission to remove some of the posterior part of the tumor. She tolerated the procedure well. She has noticed no worsening or improvement in her weakness. Pathology shows a low- to intermediate-grade glioma. The second opinion by Dr. A is still pending.

The patient is feeling well today. She is not having headache, and reports no new neurologic symptoms. She has not had leg swelling, cough, shortness of breath, or chest pain.

CURRENT MEDICATIONS:
1. Ambien p.r.n.
2. Vicodin p.r.n.
3. Actonel every Sunday.
4. Colace.
5. Felbatol 1200 mg b.i.d.
6. Heparin injections for prophylaxis.
7. Maalox p.r.n.
8. Mirapex 0.5 mg t.i.d.
9. Protonix 40 mg daily.
10. Tylenol p.r.n.
11. Zanaflex 4-mg tablet, one-half tablet daily and 6 mg at bedtime.
12. She has Zofran p.r.n., albuterol inhaler q.i.d., and Aggrenox, which she is to start.

The rest of the history is mostly from the chart.

ALLERGIES: SHE IS ALLERGIC TO PENICILLIN.

PAST MEDICAL HISTORY:
1. Parkinson's, likely secondary to radiation therapy.
2. History of prior stroke.
3. Seizure disorder secondary to her brain tumor.
4. History of urinary incontinence.
5. She has had hip fractures x2, which have required surgical pinning.
6. Appendectomy.
7. Cholecystectomy.

SOCIAL HISTORY: Shows that she does not smoke cigarettes or drink alcohol. She lives in a nursing home.

FAMILY HISTORY: Shows a family history of breast cancer.

PHYSICAL EXAMINATION:
GENERAL: Today, she is sitting up in the chair, alert, and appropriate. She tends to lean towards the right. The right arm and hand are noticeably weaker than the left. She is quite thin.
VITAL SIGNS: Temperature is 98.5, blood pressure is 138/75, pulse is 76, respirations are 16, and pulse oximetry is 92% on room air.
HEENT: There is a craniotomy incision on the left parietal region, clean, and dry with stitches still in place. The oropharynx shows no thrush or mucositis.
LUNGS: Clear bilaterally to auscultation.
CARDIAC: Exam shows regular rate.
ABDOMEN: Soft.
EXTREMITIES: No peripheral edema or evidence of deep venous thrombosis (DVT) is noted on the lower extremities.

IMPRESSION AND PLAN: Progressive low-grade glioma, now more than 20 years since initially diagnosed. She is status post craniotomy for debulking and has done well with the surgery.

We reviewed the phase II trials that have used Temodar in the setting of grade 2 gliomas. Although, complete responses are rare, it is quite common to have partial response and/or stable disease, and most patients had improved quality of life indices including many patients who benefit from decreased seizure activity. We discussed using Temodar after she heals from her surgery. Toxicities would include fatigue, nausea, and myelosuppression primarily.

The patient's insurance is through SecureHorizons plan which we do not accept at our office, so I would discuss with Dr. Y setting her up to see another oncologist. In the meantime, we can investigate the cost of Temodar to her, I suspect she may have a 20% copay.

She is anxious to have the Foley catheter removed before she goes to her nursing home tomorrow. She normally does not have a Foley catheter in place. Orders have already been written by Dr. Y to have it removed.

Keywords: consult - history and phy., low grade glioma, brain tumor, radiation therapy, seizure activity, glioma, seizure,
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