HEMATOLOGY ONCOLOGY CHART NOTE SAMPLE REPORTS
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old with myelodysplastic syndrome, on Neupogen and Aranesp. The patient is having terrible, terrible pain in his neck, which he has injured in the past.
REVIEW OF SYSTEMS: LUNGS: Unremarkable. CARDIOLOGY: Unremarkable. GI: Unremarkable. GU: Unremarkable. MUSCULOSKELETAL: Bad neck and back pain, which was chronic. NEUROLOGIC: No new motor deficits. PSYCHOLOGIC: Unremarkable. HEMATOLOGY: Unremarkable.
PHYSICAL EXAMINATION: VITAL SIGNS: Height 66, weight 190 pounds, temp 97.6 degrees, blood pressure 142/72, pulse 74, and respiratory rate 16. HEENT: Eyes: Unremarkable. HEART: Unremarkable. ABDOMEN: Unremarkable. EXTREMITIES: Unremarkable. MUSCULOSKELETAL: Tenderness in the neck area and the muscles are tight in the shoulder area. There is no significant neuro or motor deficit. SKIN: Unremarkable. HEMATOLOGIC: Unremarkable.
LABORATORY STUDIES: Hemoglobin 10.6. WBC count 3.8.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old with myelodysplastic syndrome.
1. Thrombocytopenia. Platelet count is 239, normal.
2. Leukopenia. ANC 2.7, WBC count 3.8.
3. Anemia. Hemoglobin 7. The patient on Aranesp.
4. Severe night pain. He received Neupogen and Aranesp. We are going to send him for pain management first before giving him more Neupogen. According to the patient, he got deathly sick with severe neck pain.
5. We will discontinue Neupogen and will give him Leukine.
6. The patient to see Dr. John Doe as soon as possible.
Hematology Oncology Sample #2
PRINCIPAL DIAGNOSIS: Bone marrow involvement, T-cell lymphoproliferative disorder.
RADIOGRAPHIC STUDY: CT scan of chest, abdomen and pelvis done did not reveal any adenopathy or any masses. She does have a solitary gallstone and renal cortical cyst. Otherwise, unremarkable scan.
INTERMITTENT HISTORY: The patient is here for her six-month followup. Since the last visit, she had back pain and she had fractured vertebrae. She was evaluated at the outside hospital and had kyphoplasty. Also, just a couple of days ago, she was standing on a small stool in her kitchen to reach for an object in the cabinet, she fell backward and she fractured her right arm. There is an x-ray from outside hospital; it showed impacted fracture of the radial neck. She did see Orthopedics.
REVIEW OF SYSTEMS: Her appetite is good. There is no weight loss or loss of appetite. No fever or night sweats. No frequent infection. Her energy is slow, but she said now with the weather, it is getting better. She is not having any fever or night sweats. No unusual headache, difficulty swallowing, chest pain or shortness of breath. No abdominal pain. She does have a bruise from her fall but otherwise no significant changes. The remaining review of systems was completely unremarkable.
PHYSICAL EXAMINATION: GENERAL: She is awake, alert, and oriented. VITAL SIGNS: Stable. HEENT: Within normal limits. There is no lymphadenopathy in the cervical, supraclavicular, axillary or inguinal area. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. ABDOMEN: No organomegaly. EXTREMITIES: Lower extremities: No edema. Upper extremities: She does have some bruises on her right arm, and she has a splint on her right arm. NEUROLOGIC: Examination was intact.
ASSESSMENT AND PLAN: The patient is a pleasant (XX)-year-old Hispanic female with a T-cell lymphoproliferative disorder manifested as large granular lymphocyte leukemia classified as T-cell lymphoproliferation. She does not have any involvement in any of her lymph glands. The CT scan that she had did not reveal any masses or adenopathy. Her skin inspection did not reveal any skin lesions. Today, we will repeat her CBC and see if the counts are stable. We will also review her peripheral blood smear. If the counts are stable, then we will continue to observe her and we will see her in follow up in six months from now.
Hematology Oncology Sample #3
PRINCIPAL DIAGNOSES:
1. Follicular lymphoma removed from the small intestine.
2. Abnormal PET scan showed activity in the duodenum, right supraclavicular area, and right parotid area.
RECENT PROCEDURES: Upper endoscopy and biopsy of the duodenum was completely normal.
INTERIM HISTORY: The patient is here for a followup visit after she got the PET scan, which showed the activity in the right parotid gland and the right supraclavicular area and the duodenum. She had gone through the upper GI evaluation and the upper endoscopy was completely normal, and the biopsy did not reveal any evidence of lymphoma. We asked her to come for a followup. When we did examine her before, we were not able at that time to feel any lymph node in the right supraclavicular area and that was back in February. She came today. She is feeling well and does not have any specific complaint or problem. No unusual headache. No difficulty swallowing, chest pain, or shortness of breath. No abdominal pain. No fever or night sweats. No weight loss or loss of appetite, but she said for the last week or so, she noted the development of the mass in the right supraclavicular area.
PHYSICAL EXAMINATION: GENERAL: She is awake, alert, and oriented. VITAL SIGNS: Stable. HEENT: Within normal limit. Normocephalic and atraumatic head. The pupils are equal in size. LYMPH NODES: She does indeed have a new lymph node that appeared in the right supraclavicular area; it is around 2 x 3 cm. We did not appreciate any other lymphadenopathy. ABDOMEN: Soft, no palpable masses. No organomegaly. HEART: Regular rhythm. LUNGS: Clear to auscultation and percussion. EXTREMITIES: Lower extremities: No edema. MUSCULOSKELETAL: Unremarkable. SKIN: Unremarkable.
ASSESSMENT AND PLAN: The patient is a pleasant lady who had small bowel obstruction today due to follicular lymphoma. Now, she has a sudden onset of lymph node in the right supraclavicular area. It is most likely consistent with lymphoma, but we would like to see if it is the same type as her follicular lymphoma or if it is an aggressive type. Definitely, we need to remove the right supraclavicular lymph node and she is going to see Dr. John Doe for this, and based on the pathology, then we would determine the appropriate treatment that is needed. The fact that this lymph node appeared quickly, tells us we need to address the treatment with the systemic therapy. So, this will be done after the lymph node is removed. The above was discussed in detail with the patient and she is in agreement with it.
