Oncology Hospital Note Design
Chief Complaint:
Persistent fatigue and recent weight loss.
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.
Past Medical History:
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
Allergies:
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.
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.
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.
Plan:
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.
Supportive Care:
Follow-Up:
Patient Education:
Signature:
Dr. [Your Name], MD
Attending Oncologist
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