Hematology Oncology History and Physical Medical Transcription Sample Reports


HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old woman with diffuse large B-cell lymphoma, complicated by spinal cord compression, right lower lobe pulmonary embolism, and bilateral leg deep venous thromboses. She began the R-CHOP chemotherapy regimen on MM/DD/YYYY. Cycle 2 started on MM/DD/YYYY and cycle 3 started on MM/DD/YYYY. The patient presented to my office today for a Neupogen injection. Today is cycle 3, day 10. In my office, the patient had a temperature of 101.5 degrees, and she was found to be neutropenic with WBC 0.4. She was admitted for treatment of neutropenic fever. Symptomatically, the patient reports subjective fevers, although she has no localizing symptoms suggestive of infection. She has no other complaints today. Regarding the lymphoma, the patient presented on MM/DD/YYYY with spinal cord compression. CT-guided needle biopsy of a lumbar mass on MM/DD/YYYY showed lymphocytes, which were positive for CD19, CD20, CD22, and lambda light chain, and negative for CD10. Cytology was consistent with large cell lymphoma. Bone marrow biopsy was negative. CT scans of the chest, abdomen, and pelvis showed lymphadenopathy in the left lower neck, supraclavicular areas, retroperitoneum, bilateral psoas muscles, and L1 vertebral body. LDH was mildly elevated at 276, and the patient did not have any significant symptoms. In summary, the patient has stage IV diffuse large B-cell lymphoma, based on extranodal involvement of the L1 vertebral body. On MM/DD/YYYY, the patient was admitted to the hospital with sinus tachycardia. Workup revealed pulmonary embolism and bilateral leg deep venous thromboses. The patient has been on anticoagulation. She should be taking Coumadin 2.5 mg alternating with 5 mg per day, although her compliance with this regimen has been questionable. Recently, she was found to be supratherapeutic with INR greater than 7. I instructed her to withhold Coumadin for two days, then resume at the prescribed dose. She did not have any significant hemorrhagic complications. 

PAST MEDICAL HISTORY:  Peptic ulcer disease and osteoporosis. 

PAST SURGICAL HISTORY:  None.

MEDICATIONS:  Coumadin 2.5 mg alternating with 5 mg per day and Protonix 40 mg per day. 

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY:  The patient denies alcohol and tobacco use.

FAMILY HISTORY:  There is no known history of inherited hematologic or oncologic disorders. 

REVIEW OF SYSTEMS:  CONSTITUTIONAL:  The patient reports subjective fevers x1 day. Otherwise, she denies night sweats, weight loss, fatigue or bleeding. GASTROINTESTINAL:  The patient has chronic dyspepsia, which is temporarily relieved with Mylanta or Maalox. All other systems in a 10-point review of systems were reviewed and were negative.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 110/56, heart rate 112, respiratory rate 22, and temperature 102.5.
GENERAL APPEARANCE:  The patient is alert and oriented, in no acute distress, ambulating slowly without assistance.
HEENT:  PERRL. EOMI. Sclerae anicteric. Oral mucosa clear.
PULMONARY:  Clear to auscultation bilaterally.
HEART:  Regular rate and rhythm. No murmurs.
ABDOMEN:  Soft, nontender, and nondistended. No palpable organomegaly.
EXTREMITIES:  No edema.
LYMPH NODES:  No palpable lymphadenopathy.
SKIN:  No rashes, petechiae or ecchymoses.
NEUROLOGIC:  No focal neurologic deficits, although, the patient ambulates slowly because of low back pain, which has been present since her initial presentation for spinal cord compression.

LABORATORY DATA:  WBC 0.4, hemoglobin 9.8, hematocrit 29.6, and platelets 172,000.

ASSESSMENT AND PLAN:  This is a (XX)-year-old woman with diffuse large B-cell lymphoma, pulmonary embolism, and bilateral leg deep venous thromboses, now on R-cyclophosphamide, hydroxydaunorubicin, Oncovin, prednisone cycle 3, day #10. She is now admitted with neutropenic fever without localizing signs or symptoms suggestive of infection. The patient will start empiric cefepime, and blood and urine cultures will be drawn. Neupogen 300 mcg per day will be continued. Antibiotic coverage will be adjusted based on culture findings and clinical examination. Regarding the anticoagulation for pulmonary embolism and deep venous thromboses, the patient will start Coumadin 2.5 mg per day tomorrow. Currently, she is likely to be supratherapeutic. For peptic ulcer disease, the patient will continue Protonix with the addition of p.r.n. Mylanta or Maalox.


HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male with high grade B-cell lymphoma with features of atypical Burkitt's lymphoma and complex karyotype including translocation 14;18. The patient started the R-hyper-CVAD chemotherapy regimen on MM/DD/YYYY, initially requiring hemodialysis for acute renal failure. Since that time, renal function has recovered. The patient began cycle #2 on MM/DD/YYYY, cycle #3 on MM/DD/YYYY, cycle #4 on MM/DD/YYYY, cycle #5 on MM/DD/YYYY, cycle #6 on MM/DD/YYYY, and cycle #7 on MM/DD/YYYY. The patient has tolerated his chemotherapy without significant complications, although he does have peripheral neuropathy which might have been exacerbated by vincristine. This is manifested as weakness in dorsiflexion bilaterally. For this reason, vincristine was omitted from cycle #5 through #7. I also omitted intrathecal chemotherapy starting cycle #7. Recently, on MM/DD/YYYY, the patient represented to the hospital with one day of subjective fever. He reports that his temperature was 103.5 degrees at the hospital, although he was not neutropenic. He was given intravenous hydration and empiric antibiotics and was discharged after 2 days. He did not have any localizing signs or symptoms suggestive of infection. Today, the patient feels well and he has no complaints.  

PAST MEDICAL HISTORY:  None.

PAST SURGICAL HISTORY:  Placement of an Ommaya reservoir in the past.

MEDICATIONS:
1.  Bactrim double strength 1 tablet b.i.d. on Saturdays and Sundays.
2.  Fluconazole 100 mg daily.
3.  Valtrex 500 mg daily.
4.  Neurontin 100 mg q.h.s. for peripheral neuropathy.
5.  Protonix 40 mg daily. 

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY:  The patient has a remote history of cigarette smoking, and he reports consuming 5 to 7 alcoholic drinks per week on average.

FAMILY HISTORY:  Positive for history of leukemia, unsure of the type. There is no known history of inherited hematologic or oncologic disorders.

REVIEW OF SYSTEMS:  CONSTITUTIONAL:  The patient denies fever, weight loss, night sweats, fatigue, and bleeding. NEUROLOGIC:  The patient has bilateral footdrop, although he is still able to ambulate with the assistance of a cane. All other systems in a 10-point review of systems were reviewed and were negative.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 96/68, heart rate 80, respiratory rate 18, and temperature 98.5.
GENERAL APPEARANCE:  The patient is alert and oriented, in no acute distress, ambulating with the assistance of a cane.  
HEENT:  PERRL. EOMI. Sclerae anicteric. Oral mucosa clear.  
PULMONARY:  Clear to auscultation bilaterally.
CARDIAC:  Regular rate and rhythm. No murmurs.
ABDOMEN:  Soft, nontender, and nondistended. No palpable organomegaly.
EXTREMITIES:  No edema.
LYMPH NODES:  No palpable lymphadenopathy.
SKIN:  No rashes, petechiae or ecchymosis.
NEUROLOGIC:  The patient has 4/5 motor strength on left foot dorsiflexion and 2/5 motor strength on right foot dorsiflexion. No other focal neurologic deficits.

DIAGNOSTIC DATA:  WBC 2.6, hemoglobin 9.6, hematocrit 27, platelets 44,000. The ANC is 1542. CMP is remarkable for potassium of 3.6, AST 126, ALT 74, alkaline phosphatase 178, total protein 4.8, albumin 2.7, and LDH 208.

ASSESSMENT AND PLAN:  This is a (XX)-year-old male with high grade B-cell lymphoma, who will now begin R-hyper-CVAD cycle #8. This will consist of Rituxan, high-dose methotrexate, leucovorin rescue, and high dose ara-C. I have omitted intrathecal methotrexate and ara-C from this cycle because of peripheral neuropathy. I will monitor the patient for cytopenia, especially neutropenia, and I anticipate starting Neupogen at least 24 hours after completion of chemotherapy. The patient has mildly elevated liver transaminases, which he has had during previous chemotherapy cycles. This does not require dose reduction of his chemotherapy, although I will continue to monitor the liver function tests. I explained my assessment and plan to the patient, who demonstrates adequate understanding of our discussion. He is aware of the indications and potential toxicities of each of the agent in the chemotherapy regimen. He agrees to proceed.



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