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
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Past Medical History:
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Hypertension is controlled with medication.
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Hyperlipidemia is managed with lifestyle changes.
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No previous surgeries.
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Family History:
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Father had prostate cancer diagnosed at age 70.
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Mother had breast cancer diagnosed at age 65.
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Social History:
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No smoking history.
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Moderate alcohol use (1-2 drinks per week).
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Works as a software engineer, sedentary lifestyle.
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3. Review of Systems
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General: Reports significant weight loss of 15 lbs over the last three months, fatigue, and occasional fever.
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Skin: No new rashes or lesions noted.
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Lymphatic: No swollen lymph nodes reported.
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Respiratory: No cough or shortness of breath.
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Gastrointestinal: Complains of intermittent nausea but no vomiting or changes in bowel habits.
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Neurological: No headaches, dizziness, or neurological deficits.
4. Physical Examination
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Vital Signs:
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Blood Pressure: 130/85 mmHg
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Heart Rate: 72 bpm
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Temperature: 98.6 °F
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Respiratory Rate: 16 breaths/min
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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
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Laboratory Tests:
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CBC: WBC 7,000/mm³, Hemoglobin 13.5 g/dL, Platelets 250,000/mm³.
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Liver function tests: Normal.
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Renal function tests: Serum creatinine 1.0 mg/dL.
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Imaging Studies:
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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.
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Biopsy Results:
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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.
7. Plan
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Treatment Recommendations:
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Referral to Urology for consideration of partial nephrectomy.
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Discuss potential options for active surveillance versus surgical intervention.
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Follow-Up:
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Schedule follow-up appointment in two weeks to discuss surgical options and review pathology findings.
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Patient Education:
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Discussed the nature of renal cell carcinoma, treatment options, and importance of follow-up care.
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Referrals:
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Urology for surgical evaluation.
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Nutritionist for dietary management during treatment.
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Signature:
Dr. Emily Johnson, MD, Oncology
Consulting Oncologist