SOAP / Chart / Progress Notes
Sample Name: Endometrial Cancer Followup
Description: Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.
(Medical Transcription Sample Report)
1. Stage IIIC endometrial cancer.
2. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. In March 2010, she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus. CT scan of the abdomen on 03/22/2010 showed an enlarged uterus, thickening of the endometrium, and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis. On 04/01/2010, she had a robotic modified radical hysterectomy with bilateral salpingo-oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy. The pathology was positive for grade III endometrial adenocarcinoma, 9.5 cm in size with 2 cm of invasion. Four of 30 lymph nodes were positive for disease. The left ovary was positive for metastatic disease. Postsurgical PET/CT scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease. The patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup. Of note, we had sent off genetic testing which was denied back in June. I have been trying to get this testing completed.
CURRENT MEDICATIONS: Synthroid q.d., ferrous sulfate 325 mg b.i.d., multivitamin q.d., Ativan 0.5 mg q.4 hours p.r.n. nausea and insomnia, gabapentin one tablet at bedtime.
ALLERGIES: No known drug allergies.
VITALS: BP: 100/56. HEART RATE: 84. TEMP: 97.8. Weight: 75 kg.
GEN: She has patchy alopecia.
HEENT: Pupils are equal, round, and reactive to light. Sclerae are anicteric. Oropharynx is clear. She has no stomatitis.
NECK: Supple. She has no cervical or supraclavicular adenopathy.
LUNGS: Clear to auscultation bilaterally.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Soft. He has positive bowel sounds. No hepatosplenomegaly.
SKIN: She has no skin rash.
LABORATORY DATA: White blood cell count is 5.3, hemoglobin 11, hematocrit 32.2, and platelets 273,000. Sodium 137, potassium 3.4, chloride 105, CO2 24, BUN 12, creatinine 0.75, glucose 144, calcium 9.4, total protein 7.5, albumin 3.9, total bilirubin 0.4, alkaline phosphatase 67, AST 33, ALT 23, magnesium 1.9, CEA 1257.
ASSESSMENT/PLAN: This is a very pleasant 47-year-old female with stage IIIC adenocarcinoma of the endometrial cancer. She has completed five of a planned six cycles of chemotherapy with doxorubicin, cisplatin, and Abraxane. She is slightly anemic after this last treatment and is feeling weaker. Most of this is cumulative effects of treatment. She is experiencing some neuropathy. With the Abraxane we tend to see more intensive neuropathy during treatment with improved resolution once treatment is completed. Her chemotherapy toxicities remain minimal. We will plan to proceed with cycle #6. I will see her back in the clinic after the sixth cycle. We will plan to repeat PET/CT scan about a month after she completes her sixth cycle and then she will followup with Dr. X in radiation oncology to further discuss radiation options.
Keywords: soap / chart / progress notes, adjuvant, adjuvant chemotherapy, cisplatin, adriamycin, abraxane, endometrial cancer, lymphadenectomy, chemotherapy, endometrial, disease,