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Oncology Consultation Medical Transcription Sample Report / Example

DATE OF CONSULTATION:  MM/DD/YYYY

CONSULTING PHYSICIAN:  John Doe, MD

REQUESTING PHYSICIAN:  Jane Doe, MD

Thank you for referring the patient for medical oncology consultation.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female with noninvasive left breast cancer. The patient had a screening mammogram 4 months ago, which revealed a left upper outer breast abnormality. Stereotactic biopsy previously confirmed ductal carcinoma in situ. The patient underwent needle localization excision with pathology confirming ductal carcinoma in situ grade 2, ER positive, PR positive. She received ipsilateral breast radiation. Her course has been complicated by apparent incision site infection, which has resulted in persistent low-grade oozing of blood and occasional extrusion of pus. She has been treated with several courses of antibiotics. However, the scant bloody discharge continued. Over the past 1 week, she has noted increasing tenderness at the site of bleeding and apparent infection. She otherwise offers no complaints.

PAST MEDICAL HISTORY:  Remarkable for anemia attributed to iron deficiency for which she takes iron supplements. There is no hypertension, diabetes, hypercholesterolemia or prior cardiac, pulmonary or hepatic dysfunction. She maintains normal monthly cycles; however, the last cycle has been particularly prolonged at 12 days.

MEDICATIONS:  She takes no regular prescription medications.

ALLERGIES:  NO KNOWN ALLERGIES.

FAMILY HISTORY:  Remarkable for sister with diagnosis of breast cancer at age 40, presently 47, in remission. No other known family history of breast or ovary cancer. Father died at age 74 of cardiac disease, mother aged 76 with history of heart disease; 3 brothers, 2 sons, and 1 daughter are healthy.

SOCIAL HISTORY:  Married. No cigarettes or alcohol.

REVIEW OF SYSTEMS:  No fever, chills, sweats, headaches, seizures, syncope, blurred vision, dysphagia, cough, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, constipation, melena, hematochezia, dysuria, hematuria, flank pain, back pain, abnormal bleeding, bruising, lymph node swelling or focal paresthesias or weakness.

PHYSICAL EXAMINATION:
GENERAL:  The patient is well developed, well nourished, in no acute distress.
VITAL SIGNS:  Temperature 98.6, heart rate 64, blood pressure 102/62, weight 78.4 pounds, and height 64 inches.
SKIN:  Skin clear. No rash, ecchymosis or petechia.
HEENT:  Normocephalic. No scleral icterus. No mucosal lesions.
NECK:  Supple without thyromegaly.
LYMPH NODES:  No secondary neck, axillary or inguinal nodes.
BREASTS:  Without dominant mass bilaterally. There is moderate induration of approximately 3 cm across, underlying the left upper outer quadrant incision. There is no fluctuance, erythema and no significant tenderness to the area.
CHEST:  Clear to auscultation and percussion.
CARDIAC:  Regular rate and rhythm. No murmur, rub or gallop.
ABDOMEN:  Soft and nontender. No masses or hepatosplenomegaly.
RECTAL AND GENITAL:  Deferred.
EXTREMITIES:  No clubbing, cyanosis or edema.
MUSCULOSKELETAL:  No back tenderness. No bony or joint deformity.
NEUROLOGIC:  Alert and oriented. Cranial nerves, sensory and motor system and gait are normal.

IMPRESSION:  Ductal carcinoma in situ, left breast, stage 0 (Tis N0 M0), ER positive, PR positive, status post lumpectomy to negative surgical margins and has set up breast radiation. Overall prognosis is excellent with estimated risk of local recurrence in the 5% range. Risk of systemic metastasis is negligible. Thus, adjuvant systemic therapy is not warranted. She is of course at increased risk for second malignancy, thus tamoxifen chemoprevention would be a reasonable option.

RECOMMENDATIONS AND PLAN:  Diagnosis, prognosis, and management options were discussed in detail with the patient and questions were answered. Tamoxifen chemoprevention was discussed in detail and she at present appears agreeable to initiation of therapy. There is a prescription for tamoxifen 20 mg daily. On the assumption that she desires continuing oncologic followup, any followup appointment will be made in 6 months. Alternatively, if she should decline tamoxifen chemoprevention or if her primary care physician would be willing to prescribe tamoxifen and provide continuing oncologic followup, then medical oncology followup will be on an as needed basis. 

Thank you very much for asking me to see this patient in consultation.