Oncology New Consultation

OVERALL_INSTRUCTIONS

[use singular third person in this note. do not use 'they']

Template

SYNOPSIS: [Provide the patient full name, age, sex, and city they reside in with diagnosis, including staging and specific details about the condition, if applicable.] RELEVANT Specialists: [Numbered list of relevant specialists involved] PAST MEDICAL History: [List the patient's past medical history in bullet point format, including chronic conditions, previous diagnoses, and any relevant medical issues.] PAST SURGICAL History: [List the patient's past surgical history in bullet point format, including procedures and dates, if available.] PREVIOUS RADIATION THERAPY: [Indicate whether the patient has undergone radiation therapy previously. If yes, provide details in a numbered chronologic list] HPI: [Provide a narrative of the patient's history, including presenting symptoms diagnostic findings. Include details about imaging, pathology, and any prior treatments or consultations.][Use chronological order for investigations and create a new paragraph for each diagnostic finding or consultation] CURRENT STATUS: [Write the following as it is, If certain systems have findings, replace that section with [System findings] instead] - Constitutional: No fever, chills, lethargy, malaise, fatigue, recent weight change, loss of appetite. - ENMT: No ear pain, tinnitus, loss of hearing, hearing aids, nosebleeds, sinusitis, mouth dryness, oral bleeding, mouth ulcers/yeast, altered taste, dentures, pain/difficulty swallowing, sore throat/esophagitis. - Eyes: No redness/irritation, loss of vision, blurred vision, double vision, glasses/contacts. - Endocrine: No diabetes, thyroid disease, hot flashes, night sweats. - Neck: No pain, muscle weakness, decreased range of motion, swelling, masses. - Cardiac: No chest pain, palpitations, arrhythmia, murmur, edema, dyspnea, pacemaker/defibrillator. Reports 3 stents post arm pain. No myocardial infarction. - Gastrointestinal: No nausea/vomiting, diarrhea, constipation, melena/hematochezia, hemorrhoids, GI ulcer, hiatal hernia, incontinence, weight loss. Reports reflux. - Genitourinary: No urgency, frequency, dysuria, hematuria, incontinence, slow stream, urine color change, scrotal swelling, vaginal discharge. Reports nocturia on occasion, some dribbles, weaker stream, and kidney stones. - Integumentary: No dry skin, rash, pale skin, bruising, abrasions, ulcers/wounds. - Head: No alopecia - Respiratory: No shortness of breath, cough, pleuritic chest pain, hemoptysis, wheezing, asthma, pneumonia. - Musculoskeletal: No gout, bone pain, joint pain, muscle weakness. Reports arthritis of left thumb. - Neurologic: No confusion/disorientation, dizziness, seizures, headaches, memory loss, abnormal gait, neuropathy, unilateral weakness, paralysis, stroke/TIA. - Psychiatric: No hallucinations, mood swings, change in sleeping habits, panic attacks, anxiety, depression. - Provide the patient's performance status, such as Karnofsky or ECOG score in the format of [number]% [Do not mention a symptom unless explicitly discussed] CURRENT MEDICATIONS: [[List all current medications the patient is taking, including dosages, frequency, and other medication instructions in the form of p.o. q.d when mentioned] Ex: 1. [drug_name] [dosage] p.o. q.d. 2.[drug_name] [dosage] p.o. q.d ] ALLERGIES TO DRUGS: [List any known drug allergies or indicate 'NKA' (No Known Allergies).] SOCIAL History: [Provide a narrative paragraph detailing the patient's marital status, living situation, occupation, religious preferences, appetite, smoking habits including quantity and duration, and alcohol use including frequency and quantity.][Do not mention unless explicitly discussed] FAMILY CANCER History: [Provide details about the patient's family history of cancer, if any. Or state "None that [pronoun] is aware of"] PHYSICAL EXAM: Vital signs: Height [height] inches, weight [weight] pounds, temperature [temperature], pulse [pulse], respirations [respirations], blood pressure [blood_pressure], O2 saturation [oxygen saturation].. [[Write the following examination as it is, If certain systems have findings, replace that section with [System findings] instead] General: Well-nourished, well-developed [ethnicity] male in no acute distress. HEENT: Normocephalic. Eyes EOMI, PERRLA. Sclerae are anicteric. Oral cavity is clear. No thrush or mucositis. Neck: No adenopathy. No supraclavicular or axillary adenopathy present. Lungs: Clear to auscultation bilaterally. There are no rales, rhonchi, or wheezing. Cardiac: Regular rate and rhythm with no rubs, murmurs, or gallops. Abdomen: Benign, soft, nontender. Positive bowel sounds. No masses or organomegaly. No inguinal adenopathy. Extremities: No peripheral edema or adenopathy. Neuro: Non-focal. Alert and oriented x [number]. Gait is normal. Musculoskeletal: No point tenderness to percussion or palpation of the spine. Skin: Intact. No breakdown. Psych: Mood and affect are appropriate. Remainder of examination is noncontributory. ] LABORATORY STUDIES: [Provide details of relevant laboratory studies, including dates and results. The result will include and not limited to WBC [number], hemoglobin [number], hematocrit [number], platelets [number], sodium [number], potassium [number], chloride [number], glucose [number], calcium [number], BUN [number], creatinine [number], albumin [number], total bilirubin [number], alk phos [number], ALT [number], AST [number].] For example: [Date 1]: [Lab Test and Results] [Date 2]: [Lab Test and Results] RADIOGRAPHIC STUDIES: [Provide details of relevant radiographic studies, including dates, findings, and conclusions.] For example: [[Study 1 and Date]: [Detail Findings of everything mentioned about this study in narrative format, including the specific location of each finding and measurements] Conclusion/Opinion: [Detail conclusion of each listed study listed in number list] 1. Conclusion 1 2. Conclusion 2 [[Study 2 and Date]: [Detail Findings of everything mentioned about this study in narrative format, including the specific location of each finding and measurements] Conclusion/Opinion: [detail conclusion of each listed study listed in number list] 1. Conclusion 2. Conclusion 2 ] PATHOLOGIC STUDIES: [Provide details of relevant pathologic studies, including dates, findings, and conclusions.] For example: [Study 1 and Date]: [Detail Findings of everything mentioned about this study in narrative format] [Conclusion/Comment]: [Detail conclusion or comment] [Study 2 and Date]: [Detail Findings of everything mentioned about this study in narrative format] [Conclusion/Comment]: [Detail conclusion or comment] ASSESSMENT: [Discuss treatment options with the patient, including definitive treatment recommendations. Specify the type of treatment, such as concurrent chemotherapy and radiation therapy. Include details about any scheduled procedures, such as Port-A-Cath placement. Outline the radiotherapy plan. Explain the risks, benefits, possible complications, and side effects of the treatment in depth, and confirm patient consent. Provide details about follow-up appointments, such as CT simulation, and the start of therapy. Specify the treatment plan for visible sites of disease, including draining lymphatics, total duration, and dosage.] (Narrative Format) Thank you for the referral of this patient. PLAN: [Numbered list of all diagnostic tests, medications, radiation plans that will be ordered, and the name of each test.]