Sample Type / Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Prostate Adenocarcinoma - 4
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)
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.DISCHARGE NOTE:
Patient has made good post-op recovery other than mild urgency incontinence. His post-op PSA is 0.1 mg/ml.
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,
transcribed medical transcription sample reports and examples are provided by various users and
are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.
These transcribed medical transcription sample reports may include some uncommon or unusual formats;
this would be due to the preference of the dictating physician. All names and dates have been
changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or
place or anything else to real world is purely incidental.