Hematology Oncology Medical Transcription Consultation Sample Reports

DATE OF CONSULTATION: MM/DD/YYYY

CONSULTANT: John Doe, MD

REFERRING PHYSICIAN: Jane Doe, MD

REASON FOR CONSULTATION: Anemia and metastatic pancreatic carcinoma.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who was recently diagnosed with metastatic liver disease. He underwent an evaluation at the hospital in February and underwent a liver biopsy. The liver biopsy was consistent with an infiltrating adenocarcinoma that was possibly of a biliary/pancreatic origin. Following his diagnosis, he was started on Gemzar through Dr. Doe’s office. He was admitted last night through the emergency room for uncontrolled sugars. He was recently started on prednisone to improve his appetite. This most likely is the culprit that has resulted in his uncontrolled sugars at present. He does give a history of abdominal discomfort, especially in the left upper and left lower quadrant. His discomfort has improved after starting palliative chemotherapy. The etiology of this discomfort was noted to be due to peritoneal carcinomatosis. He denies having fever, chills, rigors, nausea, vomiting, bright red blood per rectum, melena, change in bowel movements.

PAST MEDICAL HISTORY:

1. No known drug allergies.
2. Hypertension.
3. Chronic atrial fibrillation.
4. Non-insulin-dependent diabetes.
5. Dyslipidemia.
6. Atherosclerotic heart disease.
7. Carotid disease.
8. Metastatic liver disease.
9. Pancreatic carcinoma.
10. Peptic ulcer disease.
11. Colonic polyps.

PAST SURGICAL HISTORY:

1. Left inguinal hernia repair.
2. Tonsillectomy.

HABITS: He denies smoking, used to drink alcohol.

FAMILY HISTORY: Father died of prostate cancer.

MEDICATIONS AT HOME: Prednisone, Lanoxin, Zestril, Coumadin, Zoloft, Reglan, Xanax and Megace.

REVIEW OF SYSTEMS: He denies having chest pain, palpitations or shortness of breath. He denies having fever, chills or rigors. He denies having cough or wheezing. He denies having abdominal pain, bright red blood per rectum or melena. He denies having loss of consciousness, seizures or weakness. He denies having headache, blurred vision or diplopia.

PHYSICAL EXAMINATION:
GENERAL: The patient is an elderly male, lying in bed, in no apparent distress.
VITAL SIGNS: Blood pressure 142/70, pulse 90 per minute, respirations 18 per minute, oxygen saturation 96% and temperature 97.4.
HEENT: No pallor, no icterus. Extraocular muscles are intact. Pupils are round and reactive to light. Normocephalic and atraumatic.
NECK: No JVD, no cervical lymph nodes, no bruits, no thyromegaly.
LUNGS: Vesicular breath sounds heard in both lung fields. No rhonchi, no crackles, no rub.
HEART: First and second heart sounds heard, irregularly irregular rhythm. No S3, no S4, no murmurs.
ABDOMEN: Bowel sounds heard in all four quadrants. Palpable hepatomegaly with an irregular margin. Mild tenderness noted in the left upper and lower quadrant. No obvious masses palpable.
NEUROLOGIC: Alert and oriented x3. Cranial nerves II through XII intact. Motor and sensory system grossly intact. No meningeal signs. No cerebellar deficits.
EXTREMITIES: No edema. No Homans. No cyanosis. Pulses 2+.

LABORATORY AND DIAGNOSTIC DATA: PT 14.7, INR 1.4, and PTT 29.5. WBC 13.8, hemoglobin 11.7, hematocrit 34.2, and platelet count 286,000. Sodium 131, potassium 5.6, chloride 95, CO2 25.7, glucose 272, BUN 43, creatinine 1.5 and calcium 9.8. EKG: Atrial fibrillation with a heart rate of 100.

ASSESSMENT:

1. Metastatic liver disease.
2. Pancreatobiliary carcinoma.
3. Peritoneal carcinomatosis.
4. Anemia secondary to myelosuppression.
5. Uncontrolled blood sugars.

The patient is a (XX)-year-old male who was recently admitted to the hospital with significant weight loss associated with abnormal liver function tests. A CAT scan of the abdomen and pelvis noted a large mass in the tail of the pancreas and multiple hypodensities in the liver. He was seen in consultation and was subjected to a CAT scan guided liver biopsy. He was also subjected to tumor markers that included a CEA and a CA19-9. He was noted to have markedly elevated CA19-9 at 2050. His CEA was 4.3 and his alfa-fetoprotein was less than 1.2.

The CT-guided liver biopsy noted a high-grade infiltrating adenocarcinoma that was CK-7 and CAM 5.2 positive. The hepar antigen was negative. Based on this immunohistochemical staining, he was noted to have a metastatic pancreatobiliary carcinoma. His staging workup with CAT scan of the chest noted nonspecific mediastinal and axillary lymphadenopathy. The bone scan was essentially negative for metastatic disease. The CAT scan of the pelvis noted an enlarged prostate with questionable inflammatory changes on the dome of the bladder. Based on this evaluation, he was diagnosed with metastatic pancreatobiliary carcinoma and metastatic disease to the peritoneal wall and the dome of the bladder.

Following his diagnosis, he was referred to Dr. Doe’s office and has been started on palliative chemotherapy with Gemzar. He has been tolerating Gemzar without much adverse effects. He was admitted to the hospital early this morning with uncontrolled blood sugars. The most likely etiology of his uncontrolled blood sugars is prednisone therapy.

PLAN:

1. Wean off prednisone.
2. Megace 40 mg p.o. q.i.d.
3. Protonix 40 mg p.o. daily.
4. Percocet 5/325 mg p.o. q.i.d. p.r.n.
5. CBC, SMA-7.
6. Liver function tests.
7. CA19-9.
8. Sliding scale coverage.
9. Continue oral hyperglycemic therapy.
10. Continue all other cardiac medicines.
11. Repeat CBC and SMA-7 in a.m.
12. Resume palliative chemotherapy upon discharge.

Thank you, Dr. Doe, for allowing me to participate in the care of this interesting patient. I will follow the patient with you.

Hematology Oncology Medical Transcription Consultation Sample Report #2

DATE OF CONSULTATION: MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old Hispanic female with a past medical history significant for a recently diagnosed breast cancer. The patient was admitted for a planned right modified radical mastectomy, which was performed. The patient was found to have evidence of a 2.6 x 2.6 x 1.8 cm invasive ductal carcinoma with foci of ductal carcinoma in situ. The patient had 23 lymph nodes resected with 10 positive for metastatic disease. The margins were uninvolved by invasive carcinoma. The estrogen, progesterone, as well as HER2/neu receptors are still pending at this time. The patient is currently recovering relatively nicely without any major complications.

PAST MEDICAL HISTORY: The patient’s past medical history is significant for:
1. Hysterectomy.
2. Cholecystectomy.
3. Left and right hip replacement surgery.
4. Left inguinal hernia repair.
5. Lumbar laminectomy.
6. Cecal resection of a large tubulovillous adenoma of the cecum,
7. Right inguinal herniorrhaphy.

ALLERGIES: NKDA.

MEDICATIONS: The patient’s medications included:
1. Labetalol.
2. Norvasc.
3. Lisinopril/hydrochlorothiazide.
4. Bumex.

SOCIAL HISTORY: Noncontributory.

FAMILY HISTORY: Unremarkable for any underlying malignancies.

REVIEW OF SYSTEMS: In terms of review of systems, the patient denies of any significant headache, blurry vision, or double vision. No fever, shaking chills, or night sweats. No cough, no shortness of breath. The patient is having some chest wall discomfort. No abdominal pain. No nausea or vomiting. Her appetite is stable.

PHYSICAL EXAMINATION:
GENERAL: The patient is alert and oriented x3, in no distress.
VITAL SIGNS: Stable. She is afebrile.
HEENT: Oropharynx is clear. Sclerae anicteric.
NECK: Supple.
LUNGS: Clear to auscultation anteriorly.
CARDIOVASCULAR: Regular rate and rhythm. Normal S1, S2.
ABDOMEN: Soft, nontender, nondistended. Positive bowel sounds. No palpable hepatosplenomegaly. Ventral hernia palpated.
EXTREMITIES: With 1+ edema bilaterally.

LABORATORY STUDIES: Shows a white count of 6.6, hemoglobin 10.8, platelet count 208,000. Sodium 136, potassium 4.6, chloride 102, bicarbonate 26, BUN 14, creatinine 1.0, glucose 154. INR 1.0, PTT 28. AST 21, ALT 51, alkaline phosphatase 128, total bilirubin 0.4. Troponin of less than 0.5. Calcium of 8.6.

ASSESSMENT:  T2 N3 MX invasive ductal carcinoma.

PLAN:  We will check a CT scan of the chest and her pelvis to assure there is no evidence of metastatic disease. We feel it would also be reasonable to consult Radiation Oncology for adjuvant radiation therapy as the patient has multiple lymph nodes involved with an increased risk of local recurrence. We are still waiting for the estrogen, progesterone, and HER2/neu status after which we will make final recommendations in terms of hormonal therapy.

Hematology Oncology Medical Transcription Consultation Sample Report #3

DATE OF CONSULTATION: MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: A patient with history of metastatic breast carcinoma.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female with past medical history significant for metastatic breast carcinoma. The patient underwent craniotomy and biopsies were done, which were consistent with what appeared to be a breast primary. The patient did have other multiple lesions in the brain, for which she is presently undergoing radiation therapy. One week prior to presenting to the ER, the patient developed abdominal pain and some nausea, and it was with these symptoms that she presented to the hospital. Further workup revealed that her liver function tests were elevated, and as such, she was admitted to the hospital for further evaluation and management. The patient underwent a CT scan of the abdomen, which revealed intrahepatic biliary ductal dilatation. Scans done consisted of CT scan of the chest, abdomen, and pelvis and they were pretty much unremarkable, except for a 3 mm lesion in the liver, which appeared indeterminate at that time. The patient also underwent tumor marker studies done at that time, which were essentially normal as well. The patient did have a right breast mass, which was thought to be the primary. Upon interviewing the patient today, she feels somewhat better.

PAST MEDICAL HISTORY: As above and also significant for diverticulosis.

PHYSICAL EXAMINATION:
GENERAL: The patient is lying in bed and appears to be in no acute distress.
VITAL SIGNS: Stable. Afebrile.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reacting to light.
NECK: Supple. No JVD.
CHEST: Clear to auscultation.
HEART: S1 and S2.
ABDOMEN: Soft. The patient has some tenderness in the left upper quadrant.
NEUROLOGIC: No gross neurologic deficits.

LABORATORY DATA: Show a WBC count of 11.2, hemoglobin of 12.2, hematocrit of 36.6, and a platelet count of 228,000. Sodium 137, potassium 4.5, chloride 110, carbon dioxide 26, glucose 154, BUN 18, creatinine 0.6, and calcium 8.6. Total bilirubin 0.8, alkaline phosphatase 390, ALT 1084, AST 136, amylase 42, and lipase normal.

IMPRESSION: Metastatic breast carcinoma with multiple metastases to the brain, presently undergoing whole brain radiation therapy, ER/PR negative, HER2/neu positive by IHC. FISH studies were not done.

RECOMMENDATIONS: LFT abnormality demonstrated by this patient. Etiology is uncertain at this time, but medications certainly have to be considered. Possibility of this being metastatic disease to the liver certainly exists as well, but seems unlikely, since scans done about 4 weeks ago were essentially within normal limits, except for a 3 mm lesion in the liver. Agree with GI evaluation. If the patient is stable, would resume whole brain radiation therapy. We would continue to follow this patient with you.

Thank you, Dr. Doe, for involving us in the care of this patient.