Oncology New Consultation - Dec 2

OVERALL_INSTRUCTIONS

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

Chief Complaint

[Insert Chief Complaint]

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:** 1. [Specialist 1] 2. [Specialist 2] [Add more as needed] **PAST MEDICAL HISTORY:** • [Medical condition 1] • [Medical condition 2] [Add more as needed] **PAST SURGICAL HISTORY:** • [Surgical procedure 1] ([Date if available]) • [Surgical procedure 2] ([Date if available]) [Add more as needed] **PREVIOUS RADIATION THERAPY:** [Indicate whether the patient has undergone radiation therapy previously. If yes, provide details in a numbered chronologic list] **HPI:** [Provide a clear narrative of the patient’s history and presenting symptoms. Use chronological order for all investigations. Write in full sentences, and create a new paragraph for each diagnostic finding or consultation.] Example placeholder: Patient noticed [symptom] in [month/year]. Symptom is [duration] and associated with [associated findings]. Patient was referred for further evaluation by [referring provider] after [initial finding/workup]. Imaging: [Instruction: Include all imaging studies in chronological order. For each, provide: date, type of study, key findings, and any impressions that are relevant] Example placeholder: [Date][Type of imaging][description of lesion/tumor], including size, location],including size, location, and relevant features (e.g., lymph node involvement, metastases). [Optional: radiology impression]. Pathology: [Instruction: Include biopsy, surgical pathology, or cytology results. Include tumor type, grade, receptor status, molecular markers, and relevant comments.] Example placeholder: [Date][Include pathology details] Prior Treatments: Instruction: Document any prior surgery, chemotherapy, radiation, targeted therapy, or other interventions. Include dates and outcomes. Example placeholder: Received [treatment type] for [condition]. [Response/outcome]. [Notes if ongoing]. [Include any prior treatments] Prior Consultations: [Instruction: Include any consultations with surgical oncology, radiation oncology, genetics, palliative care, or other relevant specialists. Include recommendations if applicable.] Example placeholder: Seen by [specialist]. Recommendation: [summary]. [Additional notes, e.g., pending tests, referrals]. [Include any prior consultations] **CURRENT STATUS:** (Instruction: Only include items that were explicitly discussed or mentioned during the encounter.)(Do not include any “No” statements for items that were not discussed.) (Maintain the categories (Constitutional, ENMT, Eyes, Endocrine, etc.) only if there is relevant information to report.) (If a category has no findings mentioned, omit the category entirely from the note. Include performance status if explicitly reported; otherwise leave blank.) • Constitutional: [Insert only if discussed, e.g., “Reports fatigue and recent 2 kg weight changes.” "No fever", "chills", "lethargy", "malaise", "fatigue", "loss of appetite".] • ENMT: [Insert only if discussed, e.g., “Reports occasional sore throat.” "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: [Insert only if discussed, e.g., “No redness/irritation", "loss of vision", "blurred vision", "double vision", "glasses/contacts".] • Endocrine: [Insert only if discussed, e.g., “No diabetes", "thyroid disease", "hot flashes", "night sweats".] • Neck: [Insert only if discussed, e.g., “No pain", "muscle weakness", "decreased range of motion", "swelling, masses".] • Cardiac: [Insert only if discussed, e.g., “No chest pain", "palpitations", "arrhythmia", "murmur", "edema", "dyspnea", "pacemaker/defibrillator". "Reports 3 stents post arm pain". "No myocardial infarction".] • Gastrointestinal: [Insert only if discussed, e.g., “No nausea/vomiting", "diarrhea", constipation", "melena/hematochezia", "hemorrhoids", "GI ulcer", "hiatal hernia", "incontinence", "weight loss". "Reports reflux".] • Genitourinary: [Insert only if discussed, e.g., “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: [Insert only if discussed, e.g., “No dry skin", "rash", "pale skin", "bruising", "abrasions", "ulcers/wounds".] • Head: [Insert only if discussed, e.g., “"No alopecia"] • Respiratory: [Insert only if discussed, e.g., “No shortness of breath", "cough", "pleuritic chest pain", "hemoptysis", "wheezing", "asthma", "pneumonia".] • Musculoskeletal: [Insert only if discussed, e.g., “No gout", "bone pain", "joint pain", "muscle weakness". "Reports arthritis of left thumb".] • Neurologic: [Insert only if discussed, e.g., “No confusion/disorientation", "dizziness", "seizures", "headaches", "memory loss", "abnormal gait", "neuropathy", "unilateral weakness", "paralysis", "stroke/TIA".] • Psychiatric: [Insert only if discussed, e.g., “No hallucinations", "mood swings", "change in sleeping habits", "panic attacks", "anxiety", "depression".] • Performance Status: [Insert Karnofsky or ECOG score if reported] % **CURRENT MEDICATIONS:** 1. [drug_name] [dosage] p.o. q.d. 2. [drug_name] [dosage] p.o. q.d. [Add more as needed] **ALLERGIES TO DRUGS:** [List any known drug allergies or indicate 'NKA'] **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.] **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]. 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:** [Date 1]: [Lab Test and Results] [Date 2]: [Lab Test and Results] [Add more as needed] **RADIOGRAPHIC STUDIES:** [Study 1 and Date]: [Detail Findings including specific location and measurements] Conclusion/Opinion: 1. [Conclusion 1] 2. [Conclusion 2] [Study 2 and Date]: [Detail Findings including specific location and measurements] Conclusion/Opinion: 1. [Conclusion 1] 2. [Conclusion 2] **PATHOLOGIC STUDIES:** [Study 1 and Date]: [Detail Findings] [Conclusion/Comment]: [Detail conclusion or comment] [Study 2 and Date]: [Detail Findings] [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.] Thank you for the referral of this patient. **PLAN:** 1. [Diagnostic test or procedure 1] 2. [Medication or treatment 1] 3. [Radiation plan or other intervention] [Add more as needed]