SAMPLE FILE MEDICAL TRANSCRIPTION

HISTORY
1. Breast cancer. Presented in August 1999 with unattended left breast cancer. She underwent a positive biopsy and was also found to be hormone-receptor positive. She received preoperative weekly Taxol with a nice response. Following her response to the Taxol, the patient underwent a radical mastectomy on January 12, 2000. The pathology revealed a poorly-differentiated ductal carcinoma with clear margins, and 4 or 5 positive lymph nodes. A metastatic evaluation remained negative. The patient was placed on postoperative tamoxifen and remains on this agent.
2. Right brain lesion. Presented somewhat confused and disoriented a couple of weeks ago. She was seen in the office on Thursday following an MRI study. This revealed a 3.8 x 3.8 x 3-cm right frontal mass, which was enhancing and associated with edema and subfalcine herniation with a shift to the left. The differential rests between a meningioma or extra-axial metastatic lesion. The patient was placed on Decadron. She saw a doctor, who scheduled her for craniotomy tomorrow.
3. COPD. While receiving the weekly Taxol the patient required hospitalization for respiratory distress. She was seen in consultation and underwent pulmonary function testing. She was treated with nebulizer and bronchodilator treatments at that time. Bronchoscopy was performed which was nondiagnostic. Spirometry was consistent with a moderate restrictive defect.
4. Hypertension. Maintained on Adalat.

REVIEW OF SYSTEMS
Negative for recent fever, chills, or sweats. The patient has noted some difficulty with gait, and her family has noted confusion. Otherwise, she denied ENT, cardiopulmonary, GI, or GU symptomatology.

The past medical history is negative for allergies, accidents, or fractures. The patient underwent left knee replacement in the past, as well as cataract surgery. She takes an aspirin because of the history of carotid bruits.

MEDICATIONS
Adalat, Decadron, and Pepcid. Aspirin was discontinued several days ago.

SOCIAL HISTORY
Negative for recent nicotinism or alcohol ingestion. The patient has a very supportive family.

FAMILY HISTORY
Significant for a brother with lung cancer, and her father had colon cancer.

PHYSICAL EXAMINATION
Reveals a pleasant woman in no acute distress with stable vital signs. HEENT: The sclerae are white, conjunctivae are pink, mucosa is moist. The tongue is well papillated. No cervical, axillary, or inguinal adenopathy was noted. The lung fields were clear. There was a grade 2/6 systolic ejection murmur noted along the left sternal border with radiation to the carotids. The right breast was free of masses. The left chest wall was free disease recurrence. The abdominal exam failed to reveal organomegaly, masses, or tenderness. There was no peripheral edema. Distal pulses were not felt, but the feet were warm. Romberg testing was positive. Motor function and cranial nerves 2 through 12 were intact.

LABORATORY AND X-RAY DATA
WBC 12.9 (on Decadron), hemoglobin 11.1, platelets 216,000, PT 12.3, PTT 33 seconds. CMP testing normal except for glucose 142, BUN 24. Urine analysis unremarkable. EKG revealed left atrial enlargement and borderline first degree block.

In addition to the MRI noted above, the patient has had recent radiographic studies. An MRI of the lumbar spine was performed on January 8, and revealed moderate severe multilevel spondylosis with diffuse bulging and degeneration of disks. There was no evidence of metastatic disease. A bone scan performed in early December revealed increased uptake in the lumbar spine, which was evaluated with the above MRI. There was no evidence that suggests metastatic disease. A CT of the abdomen and pelvis was performed on November 29,, and was notable for the presence of renal cysts, but was otherwise unremarkable.


IMPRESSION
1. Stage III B breast carcinoma. The patient currently is without evidence of active systemic disease.
2. Right brain lesion with mass effect, rule out meningioma versus extra-axial metastatic lesion.
3. History of chronic obstructive pulmonary disease.
4. History of hypertension.

RECOMMENDATIONS
1. We will consult doctor, who has seen the patient in the past, and will be available if issues of pulmonary compromise arise.
2. Further recommendations will depend on the pathology identified at craniotomy tomorrow.