|
|||||
|
|
|||||
|
| Physical Exam | 10/10/XX |
62 year old man seen with elevated PSA. Rectal: Moderate enlargement of prostate bilaterally. Lower half of left lobe contains large nodule and has an irregular surface. |
| X-Rays & Scans | 10/20/XX |
Chest: Normal. Bone scan: Moderate increased uptake at L4. Also increased uptake in left ankle and left knee. These areas of increased uptake are consistent with arthritic changes. CT abdomen: Within normal limits. |
| Scopes | None. | |
| Laboratory | 10/01/XX | PSA: 21.8 (normal 4.0) Alk phos: 123 (normal 69 - 241). |
| Pathological Reports | 10/10/XX |
Needle biopsy: Poorly differentiated adenocarcinoma. |
| 12/05/XX | Prostatectomy: Gross: Left pelvic LNs, right pelvic LNS, prostate and vesicles. Micro: Adenoca prostate gland, Gleason’s pattern 3; perineural and seminal vesicle invasion, all margins negative. 0/19 LNs involved | |
| Treatment | 12/05/XX
|
Surgery: Bilateral pelvic lymphadenectomy and radical retropubic prostatectomy. |
