SOAP / Chart / Progress Notes
Sample Name: Prostate Adenocarcinoma - 2
Description: Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate.
(Medical Transcription Sample Report)
PHYSICAL EXAMINATION: This 71-year-old man went to his primary care physician for a routine physical. His only complaints were nocturia times two and a gradual "slowing down" feeling. The physical examination on 1/29 was within normal limits except for the digital rectal exam which revealed an asymmetric prostate gland with nodularity, R>L. PSA was elevated. The differential diagnosis for the visit was abnormal prostate, suggestive of CA.
CT pelvis: Irregular indentation of bladder. Seminal vesicles enlarged. Streaky densities in periprostatic fat consistent with transcapular spread to periprostatic plexus. Impression: prostatic malignancy with extracapsular extension and probable regional node metastasis.
Bone scan: Negative for distant metastasis.
LABORATORY: PSA 32.1
PROCEDURES: Transrectal needle biopsy of prostate. Pelvic lymphadenectomy and radical prostatectomy.
Prostate biopsy: Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate.
Lymphadenectomy and prostatectomy: Frozen section of removed pelvic lymph nodes demonstrated metastatic adenocarcinoma in one lymph node in the right obturator fossa. Therefore, the radical prostatectomy was canceled.
Final pathology diagnosis: Pelvic lymphadenectomy; left obturator fossa, single negative lymph node. Right obturator fossa; metastatic adenocarcinoma in 1/5 lymph nodes. Largest involved node 1.5 cm.
TREATMENT: Patient began external beam radiation therapy to the pelvis.
Keywords: soap / chart / progress notes, nocturia, asymmetric prostate gland, periprostatic, metastasis, poorly differentiated adenocarcinoma, differentiated adenocarcinoma, radical prostatectomy, metastatic adenocarcinoma, lymph nodes, prostatectomy, prostate, lymphadenectomy, adenocarcinoma,