Academic Medicine standard narrative

From HemOnc.org - A Hematology Oncology Wiki
Jump to: navigation, search

This exhibit is supplementary to the manuscript It’s Time to Wikify Clinical Documentation: How Collaborative Authorship Can Reduce the Burden and Improve the Quality of the Electronic Health Record.
This is a portion of a clinical narrative as it would typically appear in an electronic health record (EHR) in 2018: a series of plain-text notes. Our proposed wiki-based alternative can be found here. These notes are completely synthetic and any resemblance to a real patient is entirely coincidental. Text versions of the notes can be accessed here.

Radiology Report (1/21/2010)

===================================================================
Report ID.....................1,doc1
Patient ID....................pt123456789
Patient Name..................PatientX
Principal Date................20100121 1345
Record Type...................RAD
===================================================================
[Report de-identified (Limited dataset compliant) by De-ID v.6.24.5.1]

CLINICAL HISTORY:
50 year old peri-menopausal female who presents with new hard palpable lump
in the left breast. 

TECHNIQUE:
Full field digital mammography with CAD was performed including
routine views of both breasts, spot magnification views on the right
with a full 90 degree lateral and spot compression views on the left.

Left breast and axillary ultrasound evaluation was performed.

COMPARISON:
This study is compared to previous examinations dating back to 2004.

FINDINGS:
Heterogeneously dense fibroglandular tissue is present throughout
both breasts limiting the sensitivity of the mammogram. There is no evidence
of mass or calcifications in the right breast.

A large firm mass is seen in the upper outer left breast at the 10:30
o'clock region. The mass measures 1x2 cm on the CC view. Calcifications are
seen adjacent to the mass.

Ultrasound evaluation was performed on the area and a 1.2x3.4x5.6 cm hypoechoic
mass is seen in the left breast at the 10:30 o'clock region.

Ultrasound of the left axillary lymph nodes were performed revealing multiple
abnormally thickened lymph nodes. The largest lymph node has a thickened cortex
of at least 7 mm.

IMPRESSION:
A large hypoechoic mass at the 10:30 location of the left breast is highly
suggestive of a malignancy. The mass measures 1.2x3.4x5.6 cm. Ultrasound guided
core biopsy is recommended.

Abnormal left axillary lymph nodes are highly suspicious of metastatic disease.

MR evaluation of extent of disease is recommended.

ASSESSMENT AND RECOMMENDATIONS:
ACR BI-RADS Category:
5: (Breast Imaging Left) Highly suggestive for malignancy
RECOMMENDATION:Ultrasound guided core biopsy
OVERALL ASSESSMENT:
5 - Highly suggestive for malignancy

Initial Oncology Encounter (2/18/2010)

===================================================================
Report ID.....................3,doc3
Patient ID....................pt123456789
Patient Name..................PatientX
Principal Date................20100218
Record Type...................NOTE
===================================================================
[Report de-identified (Limited dataset compliant) by De-ID v.6.24.5.1]

HPI: Ms. PatientX is a pleasant 50 y.o. referred to the multidisciplinary breast clinic with biopsy-proven IDC, triple-negative. Earlier this year, she noticed a hard palpable lump in her left breast and sought medical attention. She has been adherent to a schedule of annual mammography since age 40, last 8 months ago and normal. No particular family history of breast cancer. She denies weight loss, change in appetite, jaundice, fatigue, or focal pain. 

PMH: Diabetes, well-controlled. Hypertension.

FHx: Mother living, dementia. Two sisters alive and well. Father d. of cerebral aneurysm, age 64

SHx: occ etoh, social. +tob 1/2 PPD x 5 years, quit 20 years ago

ALLERGIES: Morphine (rash)

MEDICATIONS:
Metformin 500 mg PO daily
Lisinopril 5 mg PO daily
Aspirin 81 mg PO daily

ROS: A complete 11-point review of systems was otherwise negative.

PE: T 98.7 HR 65 BP 134/89 RR 20 O2 98% RA
Pain: 0/10
General: mildly anxious female in NAD
HEENT: EOMI, anicteric, OP clear
Resp: CTAB, nl effort/expansion
CV: RRR, -r/g/m
Breasts: normal R breast exam. L breast with indurated mass at 10'o'clock, mobile, non-tender. No areolar discharge.
Lymph: no cervical LAD. Left axilla with possible firm matted node palpated
Abd: s/nt/nd/nabs -r/g
Ext: trace edema bilat, good pulses
Neuro: intact, normal

LABS: 
cbc wnl
chem7 & LFTs nl

IMAGING: 
Breast U/S with a large hypoechoic mass at the 10:30 location of the left breast is highly
suggestive of a malignancy. The mass measures 1.2x3.4x5.6 cm.

CT A/P negative for metastatic disease

A/P: 50F with biopsy-proven malignancy, presenting for treatment discussion. She has at least N1 TNBC. We discussed the prognostic implications of this type of breast cancer, and reviewed that treatment is multi-modal, with usually a combination of chemotherapy, surgery, and radiation. We are treating with curative intent. Given the size of the presenting primary tumor, neoadjuvant therapy is recommended.

After discussing the risks and benefits of various systemic treatment options including on clinical trial, she elects to proceed with standard therapy with weekly Taxol x 12 followed by ddAC x 4. We reviewed the potential side effects and she signed informed consent after her questions were answered to her satisfaction. She will return in one week for port-a-cath placement and to begin chemotherapy on the same day.

Progress Note (6/11/2010)

===================================================================
Report ID.....................3,doc3
Patient ID....................pt123456789
Patient Name..................PatientX
Principal Date................20100611
Record Type...................NOTE
===================================================================
[Report de-identified (Limited dataset compliant) by De-ID v.6.24.5.1]


DIAGNOSIS:  Stage IIA (T1 N1 M0) infiltrating ductal carcinoma, left breast, 
triple negative.

Therapy completed T x 9 -> AC x 4

REASON FOR VISIT:  Assess response to neoadjuvant chemotherapy.

Patient92 returns to the office today for ongoing management of biopsy-proven left breast cancer with axillary lymph node metastasis.
Her initial office visit was on February 18th, 2010.
Her clinical breast examination at that time was significant for a 2 cm palpable mass in the upper outer aspect of the left breast extending from 10:30 o'clock.
She also had multiple abnormally enlarged left axillary lymph nodes.

She has now completed 9 of a planned 12 cycles of weekly Taxol, with early discontinuation due to peripheral neuropathy. She then completed four cycles of ddAC with Neulasta support.
She has tolerated her chemotherapy overall without significant sequela; her neuropathy is beginning to improve.
She denies any hospitalizations.

Her past medical history, surgical history, medications, and allergies were reviewed as noted in the electronic medical record.

IMPRESSION:  Partial response to neoadjuvant chemotherapy for a locally advanced, triple negative, left breast cancer. She will proceed with planned modified radical mastectomy and immediate reconstruction.

Pathology Report (6/30/2010)

===================================================================
Report ID.....................2,doc2
Patient ID....................pt123456789
Patient Name..................PatientX
Principal Date................20100630 1215
Record Type...................SP
===================================================================
[Report de-identified (Limited dataset compliant) by De-ID v.6.24.5.1]


FINAL DIAGNOSIS:
PART 1:  BREAST, LEFT, MODIFIED RADICAL MASTECTOMY
A.	INVASIVE DUCTAL CARCINOMA IN UPPER OUTER QUADRANT, 1.3 CM IN
GREATEST DIMENSION ASSOCIATED WITH MICROCALCIFICATIONS.
B.	NOTTINGHAM SCORE 8/9 (TUBULES 2, NUCLEAR GRADE 3, MITOTIC RATE 3)
NOTTINGHAM GRADE 3.
C.	NO DEFINITE LYMPHOVASCULAR INVASION IDENTIFIED.
D.	SURGICAL MARGINS ARE NEGATIVE.
E.	TUMOR IS ESTROGEN RECEPTOR NEGATIVE, PROGESTERONE RECEPTOR NEGATIVE,
HER-2/NEU NEGATIVE WITHA KI-67 INDEX OF 45%.
F.	NO EVIDIENCE OF IN-SITU COMPONENT SEEN.
PART 2: AXILLARY LYMPH NODES, LEFT, BIOPSY
A. TWO OUT OF TEN AXILLARY LYMPH NODES POSITIVE FOR METASTATIC 
CARCINOMA (2/10).
B. LARGEST METATSTATIC TUMOR MEASURES 2.5 CM IN GREASTEST DIMENSION.
C. NO EXTRACAPSULAR EXTENSION IS IDENTIFIED.

COMMENT:
Immunostaining for AE1/AE3 supports the status of the axillary lymph node.

Pathologist:  Person9, M.D.
** Report Electronically Signed Out **
By Pathologist:  Person9, M.D.
1/30/2010 15:21
My signature is attestation that I have personally reviewed the submitted
material(s) and the final diagnosis reflects that evaluation.

GROSS DESCRIPTION:
The specimen is received fixed, labeled with the patient' s name, initials, 
medical record number and "left radical modified breast mastectomy". 

CASE SYNOPSIS:
SYNOPTIC - PRIMARY INVASIVE CARCINOMA OF BREAST
LATERALITY:      Left
PROCEDURE:      Modified radical mastectomy
LOCATION:      Upper outer quadrant
Clock position: 10:30
SIZE OF TUMOR:      Maximum dimension invasive component:  13 mm
MULTICENTRICITY/MULTIFOCALITY OF INVASIVE FOCI:
No
TUMOR AGGREGATE SIZE:      Sum of the sizes of multiple invasive tumors: 
TUMOR TYPE (invasive component): Ductal adenocarcinoma
NOTTINGHAM SCORE: 8     Nuclear grade: 3
Tubule formation: 2
Mitotic activity score: 3
Nottingham grade (1, 2, 3): 3
ANGIOLYMPHATIC INVASION:      No
DERMAL LYMPHATIC INVASION:      No
CALCIFICATION:      Yes
TUMOR TYPE, IN SITU:      Not present
Percent of tumor occupied by in situ component: 0 %
SURGICAL MARGINS INVOLVED BY INVASIVE COMPONENT:
No
Distance of invasive tumor to closest margin: 10 mm
SURG MARGINS INVOLVED BY IN SITU COMPONENT:
No
Distance of in situ disease to closest margin: 
PAGET's DISEASE OF NIPPLE:      No
LYMPH NODES POSITIVE:      2
LYMPH NODES EXAMINED:      10
METHOD(S) OF LYMPH NODE EXAMINATION:
H/E stain
ONLY KERATIN POSITIVE CELLS ARE PRESENT:
No
SIZE OF NODAL METASTASES:      Diameter of largest lymph node metastasis: 15 mm
LYMPH NODE METASTASIS(-ES) WITH EXTRACAPSULAR EXTENSION:
No
METASTASES TO IPSILATERAL INTERNAL MAMMARY LYMPH NODE (IF APPLICABLE):
No
SKIN INVOLVED (ULCERATION):      No
NON-NEOPLASTIC BREAST TISSUE:      ADH, FCD
T STAGE, PATHOLOGIC:      pT1c
N STAGE, PATHOLOGIC:      pN1a
M STAGE:      Not applicable
ESTROGEN RECEPTORS:      negative, H-score:  0
PROGESTERONE RECEPTORS:      negative, H-score:  0
HER2/NEU:      negative, 0
HER2/NEU (FISH):      Not applicable
--------------------------------------------------------