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Oncology Consult Medical Transcription Sample / Example Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  IgG kappa monoclonal gammopathy of undetermined significance.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who apparently had a 4-week history of at least 4 falls. The patient apparently had a right shoulder degenerative rotator cuff tear but improved at physical therapy. In addition, the patient was found to have a left inferior pubic ramus fracture and bilateral sacral chronic and acute insufficiency fractures. The patient was brought here for further evaluation and treatment. Workup including a serum protein electrophoresis was performed, which did show evidence of an IgG kappa monoclonal gammopathy of undetermined significance. We were asked to see the patient because of this finding. In general, the patient is doing well and rehab is actually going well.

PAST MEDICAL HISTORY: Significant for diabetes mellitus, coronary artery disease, osteoporosis, hypertension, osteoarthritis with a history of bilateral total knee arthroplasties with urinary incontinence, hypothyroidism and a history of a total abdominal hysterectomy. The patient also has had problems with recurrent falls in the past.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

MEDICATIONS:  Nitroglycerin, calcium carbonate with vitamin D, Lipitor, Glucophage, Catapres, Detrol LA, Zanaflex, Actonel, aspirin, multivitamin, Synthroid, Zestril, Lasix, Norvasc, K-Dur, Micronase, labetalol, sliding scale insulin, Lidoderm patch, Celebrex, insulin 70/30 and Senokot.

PHYSICAL EXAMINATION: 
GENERAL:  The patient is alert and oriented x3, in no distress.
VITAL SIGNS:  Stable. Afebrile.

LABORATORY DATA:  Lab work most recently performed showed a white count of 8.2, hemoglobin of 11.2, platelet count 372,000 with an MCV 87.6. Sodium 138, potassium 4.2, chloride 104, bicarbonate 26, BUN 26, creatinine 0.9, AST 16, ALT 34, alkaline phosphatase 233, total bilirubin 0.4, calcium of 9.9. Vitamin B12 was 507, folate 17.4. IgG 1032, IgA 162, IgM 46.

ASSESSMENT:
1. IgG kappa monoclonal gammopathy of undetermined significance.
2. Compression fracture of T12.
3. Osteoporosis.

PLAN:  At this time, I feel this likely is a monoclonal gammopathy of unknown significance. At this point in time, I do not see any evidence of myeloma. However, I would like to check a 24-hour urine for immunoelectrophoresis and a beta-2 microglobulin. This patient likely should be followed with quantitative immunoglobulin checks 1 to 2 times a year just to assure that things are not progressing.

Thank you for allowing us to participate in this patient's care. We will follow along closely in consultation.