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Medical Records


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Medical Records


The Medical Chart

The first step toward becoming empowered is to obtain a copy of your medical records. You have every right to your records. Some offices may charge a nominal fee for providing you with the records—which is reasonable. There is no universal format for charts and some offices keep more complete records than others. It may even be necessary to request the information from more than one doctor’s office to compile all the necessary information.

You don’t need a complete understanding of everything contained in the chart. However, there are certain specific items you need to look for:

1. Prostate Specific Antigen (PSA) Chronology

You need to construct a chronological history of every PSA measurement that has ever been taken and the date that it was performed. The PSA results can be located in the Lab Reports section of your chart. The testosterone level is also to be found in this section of the chart.  If you do not find the report, ask your doctor to request a testosterone level the next time you have your blood drawn.

2. Clinical Stage:

Information about the results from the finger exam of the prostate called the digital rectal examination (DRE), usually performed by a urologist, will be found in the Progress Notes section of the chart. The notes will indicate the doctor’s assessment of whether or not a nodule can be felt by the doctor’s finger. The “T” stage assessed during the digital rectal examination (DRE) is recorded in the Physical Examination section of the chart as follows:

T1: Tumor that cannot be felt by digital rectal examination

T2: Tumor confined within the prostate

T2a: Tumor that can be felt by DRE but involves 50% or less of one lobe

T2b: Tumor felt by DRE involving more than 50% of one lobe but not both lobes

T2c: Tumor felt in both lobes

T3: Tumor felt by DRE that extends through the prostate capsule

T3a: Extracapsular extension

T3b: Tumor felt by DRE that invades seminal vesicle(s)

T4: Tumor felt by DRE that invades rectum or bladder

 

3.    Radiology Reports

(imaging studies) will be found in the Radiology section of the chart. These reports may be written by the urologist (in the case of an ultrasound), or a radiologist. Look for the section in the report that says “Impression.” The Impression section of the report summarizes everything that the radiologist thinks is of importance.  Ultrasound reports or MRI reports list the size of the prostate measured in grams or cubic centimeters (cc). Men’s prostate glands vary in size, ranging between the size of a ping pong ball to the size of a small orange. Larger glands lead to a higher PSA, which impacts how PSA is interpreted (see Chapter 2). 

4.    Biopsy Report:  The biopsy report will be in the Pathology section of the chart. For each biopsy core that contains cancer, you should note the Gleason score and the percentage of the core that contains cancer (as opposed to normal prostate gland tissue). Gleason is reported as 3+3=6, 5+4=9, etc. The total number is the “score.” If several scores are present in the chart, the highest score on this report is used to describe your status (see Chapter 3).