Oncology Medical Report

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Patient Information

Patient Name:	[Your Name]
Patient ID:	123456789
Date of Birth:	January 1, 2050
Gender:	Female
Contact Information:	123-456-7890

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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.

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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.

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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.

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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.

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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.

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6. Assessment

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

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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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