Prostate Adenocarcinoma Consult Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

 REASON FOR CONSULTATION:  Prostate adenocarcinoma.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old who underwent prostate biopsies for a rising PSA.  Biopsies were negative for malignancy.  His PSA was followed and ultimately rose to 7.6 last year.  This prompted a second round of prostate biopsies showing one core positive for adenocarcinoma, Gleason score 4+3 equals 7.  Treatment options have been reviewed by Dr. John Doe.  A Radiation Oncology consultation is kindly requested.  The patient's AUA symptom score is 7.  He denies recent osseous discomforts.

PAST MEDICAL HISTORY:  Hypertension; spinal stenosis, lumbar spine, treated in the past with physical therapy and epidural steroid injection; significant hearing loss requiring hearing aids; glaucoma; elevated cholesterol; and history of GERD.

PAST SURGICAL HISTORY:  Cholecystectomy, removal of schwannoma from rib, and bilateral hip replacements.

MEDICATIONS:  Sular, Diovan, Lipitor, and Travatan ophthalmic drops.

 ALLERGIES:  None.

 FAMILY HISTORY:  Maternal cousin had breast cancer in her 30s.  Two maternal cousins had pancreatic cancer in their 40s.  A half-sister had breast cancer in her 50s.

 SOCIAL HISTORY:  The patient has three children and two stepchildren.  The patient denies tobacco use and drinks alcoholic beverages socially.

REVIEW OF SYSTEMS:  A 12-point review of systems is reviewed and placed on chart.

PHYSICAL EXAMINATION:
GENERAL:  The patient is in no acute distress.
VITAL SIGNS:  Temperature 98.2, pulse 68, respirations 18, blood pressure 156/82, and weight 182 pounds.  Pain 0 on a scale of 0 to 10.  ECOG performance status 0.
HEENT:  PERRLA, EOMI, sclerae nonicteric.  No suspicious lesions of the oral cavity.  No palpable neck adenopathy.
LUNGS:  Clear to auscultation.
HEART:  Regular rate and rhythm.
ABDOMEN:  Without tenderness, organomegaly or masses.  No inguinal adenopathy.
RECTAL:  Good sphincter tone.  There is a 0.5 cm nodule at the left prostate apex.  Prostate otherwise mildly enlarged diffusely.  No rectal masses present.
EXTREMITIES:  No clubbing, cyanosis or edema of the extremities.

LABORATORY DATA:  PSA profile as follows; 3.66, 3.76, 5.32, 4.8, 5.6, 6.36, 6.3, and 7.6.

RADIOLOGIC DATA:  By report, bone scan and chest x-ray showed no evidence of metastatic disease.

PATHOLOGY DATA:  Prostate biopsies from last year:  Adenocarcinoma, Gleason score 4+3 equals 7, involving 69% of a core taken from the left apex.  No perineural invasion seen.  High-grade prostatic intraepithelial neoplasia seen in biopsies taken from the left apex, left base, and right lateral apex.  Eight additional prostate biopsies negative for malignancy.

ASSESSMENT:  Stage T2aNxM0 prostate adenocarcinoma, Gleason score 4+3 equals 7, PSA 7.6.

RECOMMENDATIONS:  We have discussed radiotherapy treatment options with the patient.  At the outset, the patient stated that he had done significant research and was leaning more toward external beam radiation than an implant or resection, and therefore, while we briefly discussed a radioactive permanent prostate seed implant, the majority of our discussion was focused on external beam treatment.

The risks, benefits, and details of this were outlined in detail.  The patient is very interested in the different types of technology available for delivering external beam radiation.  He had questions regarding use of the TrueBeam linear accelerator, the Trilogy linear accelerator, and protons.  We discussed these as well as use of TomoTherapy and the BrainLAB Novalis system.

Overall, we do not believe there is a significant difference in the above.  However, the patient is leaning toward the TrueBeam linear accelerator.  One question which arises is whether his bilateral hip replacements will interfere with the image-guided portion of his treatment.  We will discuss this further to see if this is an issue.  If it is, an alternative would be use of TomoTherapy, which could provide image guidance for the radiation, despite the hip implants.

We also briefly discussed active surveillance, but this was not recommended in view of the Gleason 4+3 tumor seen on biopsy.  We have promised to get back to the patient after discussing things further.


Bunionectomy with Osteotomy Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Hallux abductovalgus deformity on the right lower extremity.

 POSTOPERATIVE DIAGNOSIS:  Hallux abductovalgus deformity on the right lower extremity.

 OPERATION PERFORMED:  Bunionectomy with osteotomy and internal fixation of the right foot.

SURGEON:  John Doe, MD

ANESTHESIA:  Local with IV sedation.

ESTIMATED BLOOD LOSS:  Less than 10 mL.

 SPECIMENS:  No pathologic samples were retained.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old female who presented several months ago complaining of pain associated with a bunion on the right foot.

She had undergone conservative treatment consisting of alteration in her shoe gear, orthotic devices, padding, etc., which had been ineffective in reducing symptoms, and due to the level of discomfort and limitations associated with it, the patient has opted for surgical correction.

The patient has been advised as to all possible risks and benefits of such procedure and agrees to it at this time by signing an informed consent.

DESCRIPTION OF OPERATION:  The patient was brought to the OR and placed on the operating table in the supine position.  After proper IV sedation was initiated by the anesthesiologist, local anesthesia was accomplished using approximately 8 mL of 0.5% Marcaine in the form of a modified forefoot block to the right lower extremity.  The patient was then aseptically prepped and draped in the usual fashion and a pneumatic cuff placed around her right ankle for hemostasis purposes.

After checking anesthesia, the patient was noted to be insensate, and the foot and ankle were then exsanguinated using an Esmarch bandage and the pneumatic cuff elevated to a level of approximately 250 mmHg.  After again checking anesthesia, attention was addressed to the dorsomedial aspect of the patient's right foot where a dorsal curvilinear incision was placed overlying the first metatarsophalangeal joint, approximately 6 cm long.

This was placed and deepened using sharp and dull dissection, taking care to cauterize all appropriate small vessels and preserve any neurovascular structures as indicated to the level of capsular tissue and periosteum, which was incised similar to the operative incision.  All appropriate soft tissues were then freed from the distal aspect of the first metatarsal and the base of the proximal phalanx revealing a small dorsomedial prominence, which was resected using power equipment.

The patient then had a sequential lateral release performed in the usual fashion, including the lateral capsular ligaments and the adductor tendon.  The digit assumed a much more rectus position after that procedure was performed and the sesamoid complex relocated.  The patient then had an osteotomy performed in the usual fashion using a chevron technique and fixated using a 22 mm long 2.7 absorbable screw.

The patient then had the first metatarsophalangeal joint placed through vigorous range of motion, and it was noted to be stable.  The patient then had the remainder of the first metatarsal head remodeled so as to remove any sharp edges or excess bone.  The patient then had the wound copiously irrigated using normal saline solution.  The deep soft tissue structures were reapproximated using 3-0 and 4-0 Vicryl suture and final skin closure attained using 4-0 polypropylene suture in a running interlocking technique.

The patient then had the wound cleansed and dressed using iodine-soaked Adaptic gauze, Kling and Coban.  The pneumatic cuff was then deflated.  The patient tolerated the anesthesia and the procedure well, left the OR for recovery with all vital signs stable and vascularity intact in the entire right lower extremity.

The patient was instructed as to postoperative care for bandaging as well as weightbearing status, which is full weightbearing with the use of postoperative shoe.  The patient was also educated as to all signs and symptoms of infection and asked to contact the clinic if any of those signs or symptoms should manifest.  The patient will return to the clinic in five days for first wound check.


Tibial Sesamoid Excision Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

 PREOPERATIVE DIAGNOSIS:  Chronic sesamoiditis of the left foot with elongated first metatarsal and contracted left hallux.

POSTOPERATIVE DIAGNOSIS:  Chronic sesamoiditis of the left foot with elongated first metatarsal and contracted left hallux with degenerative changes of the sesamoid apparatus of the left foot.

OPERATION PERFORMED:
1.  Excision of the tibial sesamoid and excision of the fibular sesamoid of the left foot.
2.  Fusion of the left hallux interphalangeal joint.

ANESTHESIA:  MAC, preoperative block consisted of 10 mL of 0.5% Marcaine with epinephrine.

COMPLICATIONS:  None.

TOTAL TOURNIQUET TIME:  50 minutes.

 OPERATIVE FINDINGS:  Intraoperatively, the patient did have hypertrophy of the synovium on the plantar aspect of the first metatarsophalangeal joint with the inflammatory changes and erosions of the articular surface of the tibial and fibular sesamoids.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed in the supine position on the operating table.  Anesthesiologist administered intravenous sedative agents.  A local field block was performed.  The foot and leg were prepped and draped in normal sterile technique.  Esmarch bandage used to exsanguinate the foot, and ankle tourniquet was inflated to 250 mmHg.

A plantar medial longitudinal incision was made and centered over the first metatarsophalangeal joint of the left foot.  Dissection was carefully carried down through superficial and deep fascial layer.  At this time, the capsule was identified and divided longitudinally.  The tibial sesamoid was identified and resected in toto.

There was thinning of the articular surface with chronic inflammatory changes of the surrounding soft tissues.  The flexor hallucis longus tendon was identified and gently retracted plantarly exposing the fibular sesamoid, which was also excised in toto.

The fibular sesamoid was a bipartite sesamoid with irregularities and degenerative changes.  Copious lavage was performed.  The capsular layer was closed with 3-0 Vicryl, the subcutaneous deep fascial layer was closed with 4-0 Vicryl, and the skin edges were approximated with 4-0 Prolene using a running subcuticular stitch.  Steri-Strips were applied.

A longitudinal incision was then made and centered over the interphalangeal joint of the left hallux.  Dissection was carefully carried down through superficial and deep fascial layer.  The extensor tendon was transected transversely at the level of the interphalangeal joint.  Distal articular surface of the first proximal phalanx was resected as well as the base of the distal phalanx.  The cut edges were flush.  Copious lavage was performed.

A guidepin for the 4.0 cannulated screw was then inserted through the distal aspect of the hallux and then retrograde back through the proximal phalanx.  The position was verified on fluoroscopy.  A 48 mm cannulated partially threaded screw was then inserted, and excellent compression was achieved.  The hallux now lay in a rectus position.  Copious lavage was performed.

The extensor tendon was repaired with 3-0 Vicryl, the subcutaneous layer was closed with 4-0 Vicryl, and the skin edges were approximated with 4-0 Prolene using a running subcuticular stitch.  Steri-Strips were applied.  A postoperative block was performed using 8 mL of 9:1 mixture of 0.5% Marcaine plain and dexamethasone phosphate.  Betadine-soaked Owens gauze and a bulky dry sterile dressing were applied holding the hallux in a rectus position.

The patient tolerated the procedure and anesthesia well and left the operating room for the recovery room weightbearing as tolerated with the Cam walker, and follow up with us next week for a wound check.


Cardiomyopathy Discharge Summary Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

 DATE OF DISCHARGE:  MM/DD/YYYY

FINAL DIAGNOSES:
1.  Cardiomyopathy.
2.  Atrial fibrillation, new onset, with rapid ventricular response.
3.  Congestive heart failure.

PROCEDURES PERFORMED:
1.  Left heart catheterization.
2.  Coronary angiography.
3.  Left ventriculogram.

 CONSULTANT:  John Doe, MD

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who has been in good health until two weeks prior to admission when she presented with cold symptoms, cough and congestion but no fever or chills.  She was treated with antibiotics and expectorants for acute bronchitis with mild improvement.

On the morning of admission, she became short of breath with pressure-type substernal chest pain.  She was seen at the emergency room due to worsening symptoms and was found to be in atrial fibrillation with rapid ventricular response.  Cardiac enzymes were normal.  CAT scan of the chest was negative for pulmonary embolism.  She was admitted after she was started on Cardizem drip.

PHYSICAL EXAMINATION:
GENERAL:  Revealed well-developed, well-nourished, oriented Hispanic female who was complaining of shortness of breath.
VITAL SIGNS:  Blood pressure 114/56, respirations 18, pulse 78, and temperature 98.4.
HEENT:  Normal.
HEART:  Regular rate and rhythm.
LUNGS:  Clear to auscultation.
ABDOMEN:  Benign.
EXTREMITIES:  No edema, clubbing or cyanosis.

LABORATORY DATA:  Revealed a normal CBC:  Hemoglobin 14.2, hematocrit 42.4.  Blood sugar 122, BUN 17, creatinine 1.18.  CK 86, troponin 0.06.  BNP 554.  Thyroid function test was normal.  D-dimer 1.22.

 TRANSTHORACIC ECHOCARDIOGRAM:  Left ventricle was markedly dilated.  Overall, left ventricular systolic function was moderately to markedly decreased.  Left ventricular ejection fraction was 35%.  There was severe diffuse left ventricular hypokinesis.  Left ventricular wall thickness was normal.  Left atrium was moderately dilated.  There was mild mitral annular calcification.  There was moderate mitral valvular regurgitation.  The right ventricle was moderately to markedly dilated.  Right ventricular systolic function was moderately reduced.  There was moderate tricuspid valvular regurgitation.  Right atrium was moderately dilated.

EKG:  Atrial fibrillation with rapid ventricular response at the rate of 148 beats per minute with nonspecific ST-T wave abnormality.

HOSPITAL COURSE:  The patient was admitted to telemetry bed and continued on Cardizem drip with anticoagulation with heparin.  She underwent echocardiogram with the above findings.  She was seen by Dr. John Doe in consultation.  She later developed congestive heart failure requiring diuretic treatment with ACE inhibitor.  Beta blocker was also given.

The patient underwent cardiac catheterization showing 20% stenosis of the left main coronary artery with calcification.  There was 50% proximal stenosis of the left anterior descending artery with focal 40% stenosis in the mid segment and 50% stenosis on the mid to distal segment.  At the bifurcation of the small diagonal artery, there was 50-70% ostial stenosis and 50% mid stenosis of the left circumflex artery, 50% proximal stenosis of the second obtuse marginal artery and 50-70% small focal stenosis of the mid right coronary artery being dominant artery.

Left ventriculogram showing left ventricle dilatation and globally hypokinetic with ejection fraction of 20-25%.  Left ventricular end-diastolic pressure was 33 mmHg.  Dr. Jane Doe's recommendation was to treat the patient medically with beta blocker, ACE inhibitor, and digoxin for rate control of her atrial fibrillation in addition to aspirin and lipid-lowering therapy.  Electrophysiology consultation was also obtained.  The patient remained stable throughout her hospital stay.  She was later transferred to outside hospital for further evaluation and treatment.

Cardiology Consult Sample Report  Cardiovascular Terms for Medical Transcriptionists

Shoulder Arthroscopic Decompression Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Right shoulder impingement syndrome.
2.  Right shoulder acromioclavicular joint arthritis.
3.  Right shoulder rotator cuff tear.

POSTOPERATIVE DIAGNOSES:
1.  Right shoulder impingement syndrome.
2.  Right shoulder acromioclavicular joint arthritis.
3.  Right shoulder rotator cuff tear.

OPERATION PERFORMED:
1.  Right shoulder arthroscopic decompression.
2.  Right shoulder arthroscopic distal clavicle excision.
3.  Right shoulder arthroscopic rotator cuff repair.

SURGEON:  John Doe, MD

 ASSISTANT:  None.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old female with long-standing pain in her right shoulder with an MRI proving a full-thickness tear of the rotator cuff. She is very symptomatic and presents today for arthroscopic surgery to improve her pain.

DESCRIPTION OF OPERATION:  Informed consent was obtained. She was taken to the operating room and was given interscalene as well as general anesthesia. We placed her into the lateral position with her right shoulder up. Her fingers were placed in finger traps and attached to the lateral arm holder. We prepped and draped the shoulder in routine fashion.

We made a small posterior incision and placed the arthroscope into the glenohumeral joint. She had a full-thickness tear of the supraspinatus with a lot of granulation tissue present within the tear. This tear was somewhat more medial and not really insertional. She had a lot of synovitis in her joint. We placed a shaver in the joint to perform a synovectomy and debridement of some frayed portions of her labrum. Her articular surfaces were healthy, and her biceps was intact.

We then placed the arthroscope into the subacromial space. She had a thickened bursa. We made a lateral portal and performed a complete bursectomy. The CA ligament was very thickened and calcified. We released the ligament portion to reveal a large anterior spur, and we used a motorized shaver on high speed to resect this spur. The AC joint was also very tight and arthritic. We made a direct anterior portal and used a shaver to resect the distal clavicle. This relieved the impingement.

The rotator cuff tear was in the supraspinatus, and it was a more medial side-to-side type tear. We placed a disposable cannula and performed this in a side-to-side fashion; first piercing the more lateral edge of the tendon and then grasping that suture and passing it through the more medial leaf of the tendon using a Scorpion suture Passer. We passed two sutures. These were #2 FiberWire sutures with arthroscopic knots tied more laterally, giving secure repair of tendon-to-tendon. There was no gapping and no motion at the repair site.

We then removed the instruments and closed the portals. We applied sterile dressings and a sling, and she was awakened and taken to the recovery room in good condition.


Subscribe to: Posts (Atom)