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Oncology Medical Report

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

  1. Past Medical History:

    • Hypertension is controlled with medication.

    • Hyperlipidemia is managed with lifestyle changes.

    • No previous surgeries.

  2. Family History:

    • Father had prostate cancer diagnosed at age 70.

    • Mother had breast cancer diagnosed at age 65.

  3. Social History:

    • No smoking history.

    • Moderate alcohol use (1-2 drinks per week).

    • Works as a software engineer, sedentary lifestyle.

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

  1. Vital Signs:

    • Blood Pressure: 130/85 mmHg

    • Heart Rate: 72 bpm

    • Temperature: 98.6 °F

    • Respiratory Rate: 16 breaths/min

  2. General Appearance:
    Patient appears slightly fatigued but is alert and cooperative.

  3. Head and Neck:
    No cervical lymphadenopathy, oral mucosa moist and intact.

  4. Chest/Lungs:
    Clear to auscultation bilaterally, no wheezing or crackles.

  5. Cardiovascular:
    Regular rate and rhythm, no murmurs.

  6. Abdomen:
    Soft, non-tender, but a firm mass palpated in the left flank area.

  7. Neurological:
    Cranial nerves intact, motor and sensory functions normal.

5. Diagnostic Tests

  1. 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.

  2. Imaging Studies:

    • CT Scan of Abdomen/Pelvis: A 5 cm mass in the left kidney with surrounding fat stranding, suggestive of renal cell carcinoma. No lymphadenopathy noted.

  3. Biopsy Results:

    • Fine Needle Aspiration (FNA): Confirmed renal cell carcinoma, clear cell type.

6. Assessment

The patient is diagnosed with Stage I renal cell carcinoma, left kidney. The mass is localized without evidence of metastasis.

7. Plan

  1. Treatment Recommendations:

    • Referral to Urology for consideration of partial nephrectomy.

    • Discuss potential options for active surveillance versus surgical intervention.

  2. Follow-Up:

    • Schedule follow-up appointment in two weeks to discuss surgical options and review pathology findings.

  3. Patient Education:

    • Discussed the nature of renal cell carcinoma, treatment options, and importance of follow-up care.

  4. Referrals:

    • Urology for surgical evaluation.

    • Nutritionist for dietary management during treatment.

Signature:

Dr. Emily Johnson, MD, Oncology

Consulting Oncologist

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