Clinical note · #38
Consultation
Patient: Michael Turner
Age: 66
Place of Service: Office – Outpatient
Patient Status: New Patient
Insurance: Commercial PPO
Referring Provider: Dr. S. Williams (Pulmonology)
Reason for Consultation: Oncology consultation for evaluation and management recommendations following a new diagnosis of lung cancer.
Chief Complaint: Referred after lung mass biopsy.
History of Present Illness (HPI):
The patient is a 66-year-old male referred for oncology consultation after a CT-guided biopsy of a right upper lobe lung mass revealed non-small cell lung carcinoma. He initially presented to his pulmonologist with chronic cough, progressive shortness of breath, and unintentional weight loss.
He reports a weight loss of approximately 15 pounds over four months, persistent fatigue, and decreased exercise tolerance. He denies hemoptysis, chest pain, syncope, or neurologic symptoms. No prior cancer-directed therapy has been initiated. The referring provider requested recommendations regarding staging, prognosis, and treatment options.
Review of Systems (ROS):
- Constitutional: Weight loss, fatigue
- Respiratory: Chronic cough, dyspnea
- Cardiovascular: Denies chest pain
- Neurologic: Denies focal deficits
- All other systems reviewed and negative
Past, Family, and Social History:
- PMH: Chronic obstructive pulmonary disease, hypertension
- PSH: None significant
- FH: Mother with breast cancer
- SH: Current smoker (40 pack-years)
Physical Examination:
- General: Thin male, no acute distress
- Respiratory: Decreased breath sounds in right upper lung field
- Cardiovascular: Regular rate and rhythm
- Neurologic: No focal deficits
Diagnostic Data Reviewed / Ordered:
- Pathology report reviewed confirming non-small cell lung carcinoma
- CT chest imaging reviewed
- Orders placed for PET scan and brain MRI for staging
Assessment:
- Newly diagnosed non-small cell lung carcinoma
- Chronic obstructive pulmonary disease
Plan:
- Reviewed diagnosis and prognosis with the patient
- Recommend PET scan and brain MRI for complete staging
- Discussed potential need for chemotherapy, radiation, and/or surgical intervention
- Consultation report to be sent to referring pulmonologist