Medical Specialty:
SOAP / Chart / Progress Notes
Sample Name: Prostate Adenocarcinoma - 3
Description: Moderately differentiated adenocarcinoma, 1+ enlarged prostate with normal seminal vesicles.
(Medical Transcription Sample Report)
PHYSICAL EXAMINATION: The patient is a 63-year-old executive who was seen by his physician for a company physical. He stated that he was in excellent health and led an active life. His physical examination was normal for a man of his age. Chest x-ray and chemical screening blood work were within normal limits. His PSA was elevated.
IMAGING:
Chest x-ray: Normal.
CT scan of abdomen and pelvis: No abnormalities.
LABORATORY: PSA 14.6.
PROCEDURES: Ultrasound guided sextant biopsy of prostate: Digital rectal exam performed at the time of the biopsy showed a 1+ enlarged prostate with normal seminal vesicles.
TREATMENT: The patient opted for low dose rate interstitial prostatic implants of I-125. It was performed as an outpatient on 8/10.
Keywords: soap / chart / progress notes, sextant biopsy, vesicles, seminal, apex, interstitial prostatic implants, moderately differentiated adenocarcinoma, normal seminal vesicles, enlarged prostate, gleason's, moderately, differentiated, prostate, adenocarcinoma,