Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Glioblastoma Multiforme - Consult
Asked to see the patient in regards to a brain tumor. She was initially diagnosed with a glioblastoma multiforme. She presented with several lesions in her brain and a biopsy confirmed the diagnosis.
(Medical Transcription Sample Report)
REASON FOR CONSULTATION:
We were asked to see the patient in regards to a brain tumor.HISTORY OF PRESENT ILLNESS:
She was initially diagnosed in September of this year with a glioblastoma multiforme. She presented with several lesions in her brain and a biopsy confirmed the diagnosis. She was seen by Dr. X in our group. Because of her living arrangement, she elected to have treatment through the hospital radiation department and oncology department. Details of her treatment are not available at the time of this dictation. Her family has a packet of Temodar 100-mg pills. She is admitted now with increasing confusion. A CT shows increase in size of the lesions compared to the preoperative scan. We are asked to comment on her treatment at this point. She herself is confused and is unable to provide further history. PAST MEDICAL HISTORY:
From her old chart: No known past medical history prior to the diagnosis.SOCIAL HISTORY:
She was living alone and is now living in assisted living. MEDICATIONS
1. Dilantin 300 mg daily.
2. Haloperidol 1 mg h.s.
3. Dexamethasone 4 mg q.i.d.
4. Docusate 100 mg b.i.d.
5. Pen-VK 500 mg daily.
6. Ibuprofen 600 mg daily.
7. Zantac 150 mg twice a day.
8. Temodar 100 mg daily.
9. Magic Mouthwash daily.
10. Tylenol #3 as needed.REVIEW OF SYSTEMS
: Unable.PHYSICAL EXAMINATION
GENERAL: Elderly woman, confused.
HEENT: Normal conjunctivae. Ears and nose normal. Mouth normal.
ABDOMEN: Soft, positive bowel sounds.
NEUROLOGIC: Alert, cranial nerves intact. Left arm slightly weak. Left leg slightly weak.IMPRESSION AND PLAN:
Glioblastoma multiforme, uncertain as to where she is in cancer treatment. Given the number of pills in the patient's family's hands, it sounds like she has only been treated recently and therefore it is not surprising that she is showing increased problems related to increased size of the tumor. We will have to talk with Dr. Y in the Clinic to get a better handle on her treatment regimen. At this point, I will hold Temodar today and consider restarting it tomorrow if we can get her treatment plan clarified.
consult - history and phy., temodar, brain tumor, glioblastoma multiforme, biopsy, lesions, oncology,
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