Sample Name: Prostate Adenocarcinoma - H&P
Description: Adenocarcinoma of the prostate, Erectile dysfunction - History & Physical
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: The patient is a 62-year old male with a Gleason score 8 adenocarcinoma of the prostate involving the left and right lobes. He has a PSA of 3.1, with a prostate gland size of 41 grams. This was initially found on rectal examination with a nodule on the right side of the prostate, showing enlargement relative to the left. He has undergone evaluation with a bone scan that showed a right parietal lesion uptake and was seen by Dr. XXX and ultimately underwent an open biopsy that was not malignant. Prior to this, he has also had a ProstaScint scan that was negative for any metastatic disease. Again, he is being admitted to undergo a radical prostatectomy, the risks, benefits, and alternatives of which have been discussed, including that of bleeding, and a blood transfusion.
PAST MEDICAL HISTORY: Coronary stenting. History of high blood pressure, as well. He has erectile dysfunction and has been treated with Viagra.
MEDICATIONS: Lisinopril, Aspirin, Zocor, and Prilosec.
SOCIAL HISTORY: He is not a smoker. He does drink six beers a day.
HEENT: Examination unremarkable.
Breasts: Examination deferred.
Chest: Clear to auscultation.
Cardiac: Regular rate and rhythm.
Abdomen: Soft and nontender. He has no hernias.
Genitourinary: There is a normal-appearing phallus, prominence of the right side of prostate.
Extremities: Examination unremarkable.
1. Adenocarcinoma of the prostate.
2. Erectile dysfunction.
PLAN: The patient will undergo a bilateral pelvic lymphadenectomy and radical retropubic prostatectomy. The risks, benefits, and alternatives of this have been discussed. He understands and asks that I proceed ahead. We also discussed bleeding and blood transfusions, and the risks, benefits and alternatives thereof.
Keywords: urology, gleason score, gleason, prostate gland, prostascint, retropubic prostatectomy, adenocarcinoma of the prostate, erectile dysfunction, adenocarcinoma, radical, prostatectomy, erectile, dysfunction, prostate,