Consult - History and Phy.
Sample Name: Marginal Zone Lymphoma
Description: Marginal zone lymphoma (MALT-type lymphoma). A mass was found in her right breast on physical examination. she had a mammogram and ultrasound, which confirmed the right breast mass.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Marginal zone lymphoma.
HISTORY OF PRESENT ILLNESS: This is a very pleasant 46-year-old woman, who I am asked to see in consultation for a newly diagnosed marginal zone lymphoma (MALT-type lymphoma). A mass was found in her right breast on physical examination. On 07/19/10, she had a mammogram and ultrasound, which confirmed the right breast mass. On 07/30/10, she underwent a biopsy, which showed a marginal zone lymphoma (MALT-type lymphoma).
Overall, she is doing well. She has a good energy level and her ECOG performance status is 0. She denies any fevers, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. She has normal bowel and bladder habits. No melena or hematochezia.
CURRENT MEDICATIONS: Macrobid 100 mg q.d.
ALLERGIES: Sulfa, causes nausea and vomiting.
PAST MEDICAL HISTORY:
1. She is status post a left partial nephrectomy as a new born.
2. In 2008 she had a right ankle fracture.
SOCIAL HISTORY: She has a 20-pack year history of tobacco use. She has rare alcohol use. She has no illicit drug use. She is in the process of getting divorced. She has a 24-year-old son in the area and 22-year-old daughter.
FAMILY HISTORY: Her mother had uterine cancer. Her father had liver cancer.
VIT: Height 165 cm, weight 105 kg, blood pressure 126/82, pulse is 62, and temperature is 98.2.
GEN: She is nontoxic, noncachectic appearing.
HEAD: Examined and normal.
ENT: No oropharyngeal lesions.
LYMPH: No cervical, supraclavicular, or axillary lymphadenopathy.
HEART: Regular S1, S2; no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Nontender, nondistended; normal bowel sounds; no hepatosplenomegaly.
ASSESSMENT/PLAN: MALT lymphoma. This time we need to check PET for staging purposes. I will also schedule her for a bone marrow biopsy and aspirate. The risks and benefits of an unsedated bone marrow biopsy and an aspirate were discussed with her and she consents to proceed without sedation. I am also going to schedule an EGD. I will also check a CBC, CMP and LDH. I will see her back when I have the results of her staging studies. We will then discuss further treatment at that time.
Keywords: consult - history and phy., ecog, mammogram, malt type lymphoma, marginal zone lymphoma, malt type, lymphoma, lymphadenopathy, biopsy, malt, mass, breast,