Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
|

View this sample in Blog format on MedicalTranscriptionSamples.com

Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Lymphoma - Consult

Description: Marginal B-cell lymphoma, status post splenectomy. Testicular swelling - possible epididymitis or possible torsion of the testis.
(Medical Transcription Sample Report)

HISTORY OF PRESENT ILLNESS: The patient has a known case of marginal B-cell lymphoma for which he underwent splenectomy two years ago. The patient, last year, developed a diffuse large B-cell lymphoma which was treated with CHOP/reduction. The patient again went into complete remission. The patient has been doing well until recently, few days ago, late last week, when he developed swelling of the left testicle. The patient states he has been having fever and chills for the last few days. The patient felt weak and felt unwell. The patient with these complaints came to the emergency room. The patient has been having fever and chills and the patient states that the pain in the left testicle is rather severe. No history of trauma to the testicle.

PAST MEDICAL HISTORY:
1. Status post splenectomy.
2. History of marginal B-cell lymphoma.
3. History of diffuse large cell lymphoma.

ALLERGIES: None.

PERSONAL HISTORY: Used to smoke and drink alcohol but at present does not.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS:
HEENT: Has slight headache.
CARDIOVASCULAR: No history of hypertension, MI, etc.
RESPIRATORY: No history of cough, asthma, TB, shortness of breath.
GI: Unremarkable.
GU: As above, has developed painful swelling of the left testicle over the last few days.
ENDOCRINE: Known case of type II diabetes mellitus.

PHYSICAL EXAMINATION:
HEENT: No conjunctival pallor or icterus.
NECK: No adenopathy. No carotid bruits.
LUNGS: Clear.
HEART: No gallop or murmur.
ABDOMEN: A midline scar is present.
EXTREMITIES: Unremarkable.
GENITALIA: Right testicle is markedly erythematous and swollen and tender.

LABORATORY DATA: WBC 13.8, hemoglobin 14.3, hematocrit 42.4, platelets 235,000. SMA-7 shows a potassium of 3.9. Glucose was 213 on September 18, 2007.

ASSESSMENT:
1. Left testicular swelling. It is tender. Etiology - possible epididymitis or possible torsion of the testis.
2. History of diffuse large cell lymphoma and remission.
3. History of marginal B-cell lymphoma, status post splenectomy two years ago.
4. History of diabetes mellitus.

PLAN:
1. Ultrasound of scrotum.
2. Urology consult.
3. Ultrasound of abdomen.
4. IV antibiotics.
5. We will arrange CT scan of the abdomen and pelvis in the future.

Keywords: consult - history and phy., marginal b-cell lymphoma, b-cell lymphoma, chop, splenectomy, diffuse large cell lymphoma, marginal b cell lymphoma, testicular swelling, epididymitis, swelling, torsion, lymphoma,
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.
Home | MedicalTranscriptionSamples | MT911 | MTDictionary | MTSetup | MTHelpLine
Sitemap | Tell a Friend | Contact Us | Disclaimer

Transcribed Medical Transcription Sample Reports and Examples