Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
(Depends on presentation) Cough, shortness of breath, chest pain,
hemoptysis (coughing up blood), weight loss, fatigue, other
(depending on stage and location of the tumor).
History of Present Illness:
Onset, duration, and severity of symptoms.
Smoking history (pack-years) – a major risk factor for NSCLC.
Prior respiratory illnesses (e.g., pneumonia).
Family history of lung cancer or other cancers.
Past Medical History:
Underlying medical conditions (e.g., COPD, heart disease).
Prior surgeries (chest surgeries, lung biopsies).
Social History:
Smoking history (current or former)
Occupational exposures (e.g., asbestos, radon, secondhand smoke).
Physical Exam:
General examination: Assess for vital signs (fever, hypoxia – low blood oxygen), constitutional symptoms (weight loss, fatigue).
Chest examination: Listen for abnormal breath sounds (crackles, wheezing)
suggestive of airway obstruction or fluid collection.
Laboratory Tests:
Complete blood count (CBC): May show anemia (common in advanced NSCLC).
Basic metabolic panel (BMP): To assess overall health and electrolyte balance.
Sputum cytology (if productive cough): Microscopic examination of
sputum to look for cancer cells (not definitive but can raise suspicion).
Imaging Studies:
Chest X-ray: Initial imaging study to visualize the lungs and may show
a mass or nodule.
(Definitive diagnosis usually requires):
Chest CT scan: Provides detailed images of the lungs and
mediastinum (area between the lungs) to assess tumor size, location, and
possible spread to lymph nodes.
PET scan (may be used for staging or evaluating for recurrence):
Shows areas of increased metabolic activity which can help identify
cancer spread.
Biopsy:
Tissue biopsy is essential for definitive diagnosis. Biopsy can be
obtained through various methods (bronchoscopy, CT-guided needle biopsy,
surgical biopsy) depending on the tumor location and accessibility.
Assessment:
Non-small cell lung cancer (NSCLC): Suspected based on clinical
presentation (symptoms, risk factors) and imaging studies. Confirmed by
tissue biopsy.
Histological subtype of NSCLC: There are different subtypes of NSCLC
(e.g., adenocarcinoma, squamous cell carcinoma) with implications for
treatment and prognosis.
Stage of NSCLC: NSCLC is staged based on the size and location of the tumor, involvement of lymph nodes, and distant metastasis. Staging
determines treatment options and prognosis.
Performance status: Assesses a patient’s overall health and ability
to tolerate treatment.
Differential Diagnoses:
Consider other causes of symptoms:
Pneumonia
Pulmonary embolism (blood clot in the lung)
Chronic obstructive pulmonary disease (COPD)
Tuberculosis (less common)
Plan:
The treatment plan for NSCLC is based on stage, histology, and
performance status. Possible elements include:
Surgery (curative intent if possible): Removal of the tumor
and surrounding lung tissue with the goal of cure.
Chemotherapy: Uses medications to kill cancer cells throughout
the body. May be used before or after surgery, or as the main treatment
for advanced stages.
Radiation therapy: Uses high-energy rays to kill cancer cells.
May be used alone or in combination with surgery or chemotherapy.
Targeted therapy: Medications that target specific molecular
abnormalities in cancer cells. May be an option for specific mutations.
Immunotherapy: Helps the body’s immune system fight cancer cells.
A relatively new treatment option for NSCLC.
Supportive care: Pain management, nutritional support