Medical Specialty:
SOAP / Chart / Progress Notes
Sample Name: Prostate Adenocarcinoma - 4
Description: Prostate gland showing moderately differentiated infiltrating adenocarcinoma - Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.
(Medical Transcription Sample Report)
PHYSICAL EXAMINATION: Patient is a 46-year-old white male seen for annual physical exam and had an incidental PSA elevation of 4.0. All other systems were normal.
PROCEDURES:
Sextant biopsy of the prostate.
Radical prostatectomy: Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.
PATHOLOGY:
Prostate biopsy: Right lobe, negative. Left lobe, small focus of adenocarcinoma, Gleason's 3 + 3 in approximately 5% of the tissue.
Radical prostatectomy: Negative lymph nodes. Prostate gland showing moderately differentiated infiltrating adenocarcinoma, Gleason 3 + 2 extending to the apex involving both lobes of the prostate, mainly right. Tumor overall involved less than 5% of the tissue. Surgical margin was reported and involved at the apex. The capsule and seminal vesicles were free.
Keywords: soap / chart / progress notes, capsule, bladder neck, surgical margin, moderately differentiated infiltrating adenocarcinoma, pelvic lymph nodes, prostate gland, infiltrating adenocarcinoma, radical prostatectomy, seminal vesicles, gleason's, seminal, vesicles, adenocarcinoma, prostate,
