Oncology Medical Report
Patient Information
Patient Name: | [Your Name] |
Patient ID: | 123456789 |
Date of Birth: | January 1, 2050 |
Gender: | Female |
Contact Information: | 123-456-7890 |
1. Reason for Consultation
The patient was referred for evaluation of persistent abdominal pain and unexplained weight loss over the past three months. A CT scan performed at the referring physician's office revealed a mass in the left kidney, suspected to be renal cell carcinoma.
2. Medical History
Past Medical History:
Family History:
Social History:
3. Review of Systems
General: Reports significant weight loss of 15 lbs over the last three months, fatigue, and occasional fever.
Skin: No new rashes or lesions noted.
Lymphatic: No swollen lymph nodes reported.
Respiratory: No cough or shortness of breath.
Gastrointestinal: Complains of intermittent nausea but no vomiting or changes in bowel habits.
Neurological: No headaches, dizziness, or neurological deficits.
4. Physical Examination
Vital Signs:
General Appearance:
Patient appears slightly fatigued but is alert and cooperative.
Head and Neck:
No cervical lymphadenopathy, oral mucosa moist and intact.
Chest/Lungs:
Clear to auscultation bilaterally, no wheezing or crackles.
Cardiovascular:
Regular rate and rhythm, no murmurs.
Abdomen:
Soft, non-tender, but a firm mass palpated in the left flank area.
Neurological:
Cranial nerves intact, motor and sensory functions normal.
5. Diagnostic Tests
Laboratory Tests:
CBC: WBC 7,000/mm³, Hemoglobin 13.5 g/dL, Platelets 250,000/mm³.
Liver function tests: Normal.
Renal function tests: Serum creatinine 1.0 mg/dL.
Imaging Studies:
Biopsy Results:
6. Assessment
The patient is diagnosed with Stage I renal cell carcinoma, left kidney. The mass is localized without evidence of metastasis.
7. Plan
Treatment Recommendations:
Follow-Up:
Patient Education:
Referrals:
Signature:
Dr. Emily Johnson, MD, Oncology
Consulting Oncologist
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