Consult - History and Phy.
Sample Name: Supraclavicular Lymphadenopathy
Description: The patient was undergoing a routine physical examination and was found to have right supraclavicular lymphadenopathy. She returned for followup examination and again was noted to have right supraclavicular lymphadenopathy. She is now referred to the thoracic surgery clinic for evaluation.
(Medical Transcription Sample Report)
The patient is a 51-year-old female who was undergoing a routine physical examination and it was noticed that she had right supraclavicular lymphadenopathy in August 2009. She returned for followup examination in October 2009 and again was noted to have right supraclavicular lymphadenopathy. She is now referred to the thoracic surgery clinic for evaluation.
On review of systems, the patient admits to hypertension and occasional heartburn. She undergoes mammograms every six months, which have been negative for malignancy. She denies fevers, chills, weight loss, fatigue, diabetes mellitus, thyroid disease, upper extremity trauma, night sweats, DVT, pulmonary embolism, anorexia, bone pain, headaches, seizures, angina, peripheral edema, claudication, orthopnea, PND, coronary artery disease, rheumatoid arthritis, rashes, upper extremity edema, cat scratches, cough, hemoptysis, shortness of breath, dyspnea at two flights of stairs, hoarseness, GI bleeding, change in bowel habits, dysphagia, ulcers, hematuria, or history of TB exposure. She has had negative PPD.
PAST MEDICAL HISTORY: Hypertension.
PAST SURGICAL HISTORY: Right breast biopsy - benign.
SOCIAL HISTORY: She was born and raised in Baltimore. She has not performed farming or kept birds or cats.
Occupation: She is a registered nurse at Spring Grove Hospital.
Exposure: Negative to asbestos.
FAMILY HISTORY: Mother with breast cancer.
ALLERGIES: Percocet and morphine causing temporary hypotension.
MEDICATIONS: Caduet 10 mg p.o. q.d., Coreg CR 40 mg p.o. q.d., and Micardis HCT 80 mg/12.5 mg p.o. q.d.
PHYSICAL EXAMINATION: BP: 133/72 P: 56 R: 14 H: 5'5" WT: 271 lbs. RAS: 94%
Eyes: Anicteric sclerae. EOMs intact. Pupils equal and reactive to light and accommodation.
Head and Face Normocephalic and atraumatic.
ENT: Oropharynx clear. Mucous membranes are moist.
Neck: No thyroid enlargement. No carotid bruits.
Lymphatic: Palpable mobile firm 3 x 3 cm right supraclavicular lymphadenopathy in fat pad. No cervical or axillary lymphadenopathy.
Lungs: Clear to auscultation bilaterally.
Cardiac: Regular rate and rhythm without murmurs.
Abdomen: Soft, nondistended, and nontender. No organomegaly.
Neuro: Alert and oriented x 3. Cranial nerves II through XII intact. Mood and affect appropriate.
Musculoskeletal: Gait normal, strength intact.
ASSESSMENT/PLAN: This is a 51-year-old African-American female with right supraclavicular lymphadenopathy representing inflammatory disease versus sarcoidosis. There is a remote chance that this could represent lymphoma. The indications, benefits, and risk of undergoing a right supraclavicular lymph node biopsy were discussed with the patient. She understands and would like to proceed. This will be scheduled within the next several weeks.
Keywords: consult - history and phy., supraclavicular, sarcoidosis, inflammatory disease, lymphoma, thoracic surgery, supraclavicular lymphadenopathy,