Oncology Hospital Note Design

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• Name: Tom Walter

• DOB: January 15, 2050

• MRN: 123456

• Date: October 8, 2099

• Attending Physician: Dr. [Your Name]

• Referring Physician: Dr. Alan Brown

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Chief Complaint:

Persistent fatigue and recent weight loss.

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History of Present Illness (HPI):

Tom Walter is a 49-year-old male with a history of stage IIIB non-small cell lung cancer, diagnosed 6 months ago. He presents today with complaints of increased fatigue over the past month, accompanied by a 10-pound weight loss. He reports difficulty breathing during exertion and has experienced a mild cough. No new pain was reported. He completed his last round of chemotherapy 3 weeks ago and has been experiencing mild nausea, managed with ondansetron.

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Past Medical History:

• Non-small cell lung cancer, Stage IIIB

• Hypertension

• Type 2 diabetes mellitus

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Medication List:

• Ondansetron 8 mg orally, as needed for nausea

• Lisinopril 10 mg orally once daily

• Metformin 1000 mg orally twice daily

• Atezolizumab 1200 mg IV every 3 weeks

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Allergies:

• No known drug allergies.

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Physical Exam:

• General Appearance: Alert, in mild respiratory distress.

• Vital Signs: BP 130/85 mmHg, HR 88 bpm, Temp 98.6°F, RR 20 breaths/min, O2 Sat 92% on room air.

• Head and Neck: No lymphadenopathy, oral mucosa moist.

• Chest/Lungs: Decreased breath sounds bilaterally, wheezing noted, mild crackles.

• Cardiovascular: Regular rate and rhythm, no murmurs.

• Abdomen: Soft, non-tender, no organomegaly.

• Extremities: No edema, pulses intact.

• Neurological: Alert and oriented, cranial nerves II-XII intact.

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Laboratory and Imaging Results:

• CBC: Hemoglobin 11.2 g/dL, WBC 7,500/mm³, Platelets 180,000/mm³ (anemia noted).

• CT Chest: Increased size of right upper lobe mass, stable mediastinal lymphadenopathy.

• Pulmonary Function Tests: Mild obstructive pattern.

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Assessment:

The patient is a 49-year-old male with progressive symptoms consistent with advanced lung cancer. Recent imaging shows disease progression. The patient is experiencing treatment-related fatigue and anemia.

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Plan:

1. Treatment:

   • Discuss the initiation of palliative care with the patient and family.

   • Continue the current chemotherapy regimen with Atezolizumab.

   • Consider referral for radiation therapy to manage symptoms related to the lung mass.

2. Supportive Care:

   • Increase ondansetron to manage nausea more effectively.

   • Consult with a nutritionist for dietary adjustments to address weight loss.

3. Follow-Up:

   • Schedule a follow-up appointment in 2 weeks to reassess symptoms and response to treatment.

   • Order a repeat CT scan in 6 weeks to evaluate treatment efficacy.

4. Patient Education:

   • Provided educational materials on lung cancer treatment options and palliative care resources.

   • Discussed signs and symptoms of potential complications to monitor at home.

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Signature:

Dr. [Your Name], MD

Attending Oncologist

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