Sample Name: Gen Med H&P - 1
Description: History and Physical - A history of stage IIIC papillary serous adenocarcinoma of the ovary, presented to the office today left leg pain (left leg DVT).
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Left leg pain.
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old gravida 1, para 0-0-1-0, with a history of stage IIIC papillary serous adenocarcinoma of the ovary who presented to the office today with left leg pain that started on Saturday. The patient noticed the pain in her left groin and left thigh and also noticed swelling in that leg. A Doppler ultrasound of her leg that was performed today noted a DVT. She is currently on course one, day 14 of 21 of Taxol and carboplatin. She is scheduled for intraperitoneal port placement for intraperitoneal chemotherapy to begin next week. She denies any chest pain or shortness of breath, nausea, vomiting, or dysuria. She has a positive appetite and ambulates without difficulty.
PAST MEDICAL HISTORY:
1. Gastroesophageal reflux disease.
2. Mitral valve prolapse.
3. Stage IIIC papillary serous adenocarcinoma of the ovaries.
PAST SURGICAL HISTORY:
2. Bone fragment removed from her right arm.
3. Ovarian cancer staging.
OBSTETRICAL HISTORY: Spontaneous miscarriage at 3 months approximately 30 years ago.
GYNECOLOGICAL HISTORY: The patient started menses at age 12; she states that they were regular and occurred every month. She finished menopause at age 58. She denies any history of STDs or abnormal Pap smears. Her last mammogram was in April 2005 and was within normal limits.
1. A sister with breast carcinoma who was diagnosed in her 50s.
3. The patient denies any history of ovarian, uterine, or colon cancer in her family.
SOCIAL HISTORY: No tobacco, alcohol, or drug abuse.
2. Tramadol p.r.n.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
VITAL SIGNS: Temperature 97.3, pulse 91, respiratory rate 18, blood pressure 142/46, O2 saturation 99% on room air.
GENERAL: Alert, awake, and oriented times three, no apparent distress, a well-developed, well-nourished white female.
HEENT: Normocephalic and atraumatic. The oropharynx is clear. The pupils are equal, round, and reactive to light.
NECK: Good range of motion, nontender, no thyromegaly.
CHEST: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.
CARDIOVASCULAR: Regular rate and rhythm with a 2/6 systolic ejection murmur on her left side.
ABDOMEN: Positive bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly, a well-healing midline incision.
EXTREMITIES: 2+ pulses bilaterally, right leg without swelling, nontender, no erythema, negative Homans' sign bilaterally, left thigh swollen, erythematous, and warm to the touch compared to the right. Her left groin is slightly tender to palpation.
LABORATORY DATA: White blood cell count 15.5, hemoglobin 11.4, hematocrit 34.5, platelets 159, percent neutrophils 88%, absolute neutrophil count 14,520. Sodium 142, potassium 3.3, chloride 103, CO2 26, BUN 15, creatinine 0.9, glucose 152, calcium 8.7. PT 13.1, PTT 28, INR 0.97.
ASSESSMENT AND PLAN: Miss Bolen is a 59-year-old gravida 1, para 0-0-1-0 with stage IIIC papillary serous adenocarcinoma of the ovary. She is postop day 21 of an exploratory laparotomy with ovarian cancer staging. She is currently with a left leg DVT.
1. The patient is doing well and is currently without any complaints. We will start Lovenox 1 mg per kg subcu daily and Coumadin 5 mg p.o. daily. The patient will receive INR in the morning; the goal was obtain an INR between 2.5 and 3.0 before the Lovenox is instilled. The patient is scheduled for port placement for intraperitoneal chemotherapy and this possibly may be delayed.
2. Aranesp 200 mcg subcu was given today. The patient's absolute neutrophil count is 14,520.
Keywords: general medicine, history and physical, dvt, doppler ultrasound, h&p, adenocarcinoma, leg pain, ovarian cancer, papillary serous adenocarcinoma, serous adenocarcinoma, swelling, adenocarcinoma of the ovary, absolute neutrophil count, serous, papillary,