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: Consult - Breast Cancer

Description: Patient presents with complaint of lump in the upper outer quadrant of the right breast
(Medical Transcription Sample Report)

CHIEF COMPLAINT / REASON FOR THE VISIT: Patient has been diagnosed to have breast cancer.

BREAST CANCER HISTORY: Patient presented with the following complaints: Lump in the upper outer quadrant of the right breast that has been present for the last 4 weeks. The lump is painless and the skin over the lump is normal. Patient denies any redness, warmth, edema and nipple discharge. Patient had a mammogram recently and was told to have a mass measuring 2 cm in the UOQ and of the left breast. Patient had an excisional biopsy of the mass and subsequently axillary nodal sampling.

PATHOLOGY: Infiltrating ductal carcinoma, Estrogen receptor 56, Progesterone receptor 23, S-phase fraction 2., Her 2 neu 0 and all nodes negative.

STAGE: Stage I.

TNM STAGE: T1, N0 and M0.

SURGERY: S/P lumpectomy left breast and Left axillary node sampling. Patient is here for further recommendation.

PAST MEDICAL HISTORY: Osteoarthritis for 5 years. ASHD for 10 years. Kidney stones recurrent for 10 years.

SCREENING TEST HISTORY: Last rectal exam was done on 10/99. Last mammogram was done on 12/99. Last gynecological exam was done on 10/99. Last PAP smear was done on 10/99. Last chest x-ray was done on 10/99. Last F.O.B. was done on 10/99-X3. Last sigmoidoscopy was done on 1998. Last colonoscopy was done on 1996.

IMMUNIZATION HISTORY: Last flu vaccine was given on 1999. Last pneumonia vaccine was given on 1996.

FAMILY MEDICAL HISTORY: Father age 85, history of cerebrovascular accident (stroke) and hypertension. Mother history of CHF and emphysema that died at the age of 78. No brothers and sisters. 1 son healthy at age 54.

PAST SURGICAL HISTORY: Appendectomy. Biopsy of the left breast 1996 - benign. Cholecystectomy.

PERSONAL AND SOCIAL HISTORY: Marital status: Married. Smoking history: Smoked 1 PPD, quit 12 years ago and after smoking for 30 years. Alcohol history: Drinks socially. Denies any history of drug abuse.

ALLERGIES: There are no known drug allergies.

CURRENT MEDICATIONS: Aspirin 1 tab x 1 / day. Calan SR 120 mg. x 1 / day.

REVIEW OF SYSTEMS:
General: Patient feels fairly well. Patient denies history of fever, chills, night sweats and weight loss.
Head and Eyes: Patient denies any problems relating to the head and eyes.
Ears Nose and Throat: Patient has no problems related to the ears, nose or throat.
Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.
Cardiovascular: Chest pain in the retrosternal area, Occasional anginal pain and patient describes it as a sensation of tightness. It radiates to the left shoulder. Patient denies any palpitation, syncope, paroxysmal nocturnal dyspnea and orthopnea.
Gastrointestinal: Patient denies any nausea, vomiting, abdominal pain, dysphagia or any altered bowel movements.
Genitourinary: Denies any genito-urinary complaints.
Musculoskeletal: The patient denies any musculoskeletal complaints.
Neurological: Patient denies any focal motor, sensory or other neurological symptoms.

PHYSICAL EXAMINATION:
General: Patient appears well developed, well nourished and healthy. Personality: pleasant and cooperative. Mental status: Alert and oriented. Stature: slender. ECOG performance score 0.
HEENT: Examination of head, eyes, ears, nose and throat is unremarkable.
Hematologic / Lymphatic: There is no palpable adenopathy in the inguinal, axillary, or cervical areas.
Cardiovascular: Heart: Regular rhythm, normal rate without any murmurs or gallops.
Breast: RIGHT BREAST: Within normal limits. LEFT BREAST: Consistency: slight induration noted due to recent surgery.
Respiratory: Chest symmetrical, normal, breath sounds equal, bilateral symmetrical, no rales or rhonchi and no
dullness to percussion.
Abdomen / Gastrointestinal: Abdomen is soft, non-tender, and without palpable masses. No hepatosplenomegaly is appreciable.
Extremities: Peripheral pulses are normal. There is no edema, cyanosis, clubbing or significant varicosities. No skin lesions identified.
Musculoskelatal: No evidence of joint swelling, bone tenderness or muscle tenderness is appreciable.
Neurological: Brief neurological examination reveals motor power grossly normal in all groups and no gross sensory or other abnormality appreciable.

RADIOLOGY: Mammogram: A mass measuring 2X2 cm. in the upper outer quadrant of the left breast. Lab:

LAB DATA: CMP (comprehensive metabolic panel): WNL. Liver function tests are WNL. CBC with diff shows WBC 3.2 / cmm. Hemoglobin 12.0 grams / dl, Platelets 250000 / cmm and it is dated 1/4/2000.

IMPRESSION / DIAGNOSIS : Carcinoma of the left breast (174.9 - female), Upper outer quadrant (174.4)

PATHOLOGY: Infiltrating ductal carcinoma. S/P lumpectomy and axillary node dissection. (Details as per HPI).

DISCUSSION: Discussed in detail the diagnosis, prognosis and treatment alternatives. Options of treatment discussed. Side effects of Tamoxifen discussed in detail.

RECOMMENDATIONS: Hormonal therapy with Tamoxifen and Radiation therapy to the breast is recommended.

TESTS ORDERED: The following labs are to be drawn about a week or so prior to next appointment:
HEMATOLOGY: CBC.
CHEMISTRY: comprehensive metabolic panel (CMP) and liver function panel (LFT).

MEDICATIONS PRESCRIBED: Nolvadex 20 mg. 1 time a day.

FOLLOW-UP INSTRUCTIONS: Return to see William Smith.M.D. for follow up in 3 month (s). Make appointment to Radiation therapy.

Keywords: consult - history and phy., breast cancer, lump, progesterone receptor, estrogen receptor, her 2 neu, tnm, axillary node dissection, tamoxifen, infiltrating ductal carcinoma, upper outer quadrant, ductal carcinoma, breast, carcinoma, axillary, chest, mammogram,
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