Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Mesothelioma Consult Medical Transcription Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:
Mesothelioma.

HISTORY OF PRESENT ILLNESS:
The patient is a (XX)-year-old Hispanic gentleman with history of mesothelioma, recurrent malignant pleural effusion, for which he has a PleurX catheter and drains about 900 liters of fluid every day. The patient has been heavily pretreated. Initially, the patient received treatment with Alimta and currently is receiving therapy with gemcitabine. Prior to coming to this facility, he was being treated by an outside oncologist.

The patient came to the emergency room with a complaint of worsening shortness of breath and chest pain. A CT scan of the chest revealed recurrent pleural effusion and possible pulmonary embolism. The patient then got admitted in the intensive care unit for aggressive respiratory support. The patient was also placed on heparin, now slowly being switched to Coumadin.

At this time, the patient’s breathing has somewhat improved. The pain has resolved, and he is asking to undergo scheduled chemotherapy.

REVIEW OF SYSTEMS:
EYES:  No visual changes.
ENT:  No ear, nose or throat pain.
PULMONARY:  Extreme shortness of breath and tachypnea, improved.
GASTROINTESTINAL:  Poor appetite.

PAST MEDICAL HISTORY:
Mesothelioma of the left lung.

SOCIAL HISTORY:
The patient lives at home and he smoked 2 packs a day for 20 years in the past.

MEDICATIONS ON ADMISSION:
1.  Protonix.
2.  Zoloft.
3.  Duragesic patch 50 mcg q. 72 h.
4.  Ativan 1 mg.
5.  Home oxygen

ALLERGIES:
No known drug allergies.

PHYSICAL EXAMINATION:
GENERAL:  The patient is alert and oriented x3.
HEENT:  Negative.
NECK:  Negative for JVD.
CHEST:  Decreased breath sounds on the left with rhonchi.
CARDIOVASCULAR:  Regular rate and rhythm.
ABDOMEN:  Soft and nontender. Liver, spleen and kidneys are not palpable.
EXTREMITIES:  No edema.
NEUROLOGICAL:  No focal deficit.

LABORATORY DATA:  PTT 46, on heparin. Comprehensive metabolic profile revealed potassium 4.6, creatinine 0.7, magnesium 1.6 and liver enzymes are in the normal range.  CBC shows WBC 10.4, hemoglobin 11.6, platelets 162.

Echocardiogram shows normal left ventricular size with good contractility. Little or no pericardial effusion was seen. No intracardiac masses were noted.

ASSESSMENT:
1.  Pulmonary embolism.
2.  Mesothelioma, for which he is on palliative therapy with gemcitabine.
3.  Hypoxemia and chronic obstructive pulmonary disease.
4.  Recurrent left pleural effusion. The patient has PleurX catheter in place.
5.  Electrolyte imbalance.

PLAN:
1.  Anticoagulation.
2.  Weekly gemcitabine.

The findings were discussed with the patient and his family.  Overall prognosis appears to be poor.