New Patient Consultation Note

New Patient Consultation Note Referral Details: Patient referred for evaluation of a suspicious lung mass identified on a routine chest X-ray. Initial referral mentioned suspected malignancy based on imaging characteristics and patient's smoking history. History: Presenting symptoms include a persistent cough for approximately 3 months, occasional shortness of breath with exertion, and unintentional weight loss of 5 kg over the past 2 months. No haemoptysis reported. Prior medical consultations confirmed the lung mass and recommended specialist oncology review. Family history is significant for lung cancer in the paternal grandmother. Patient is a current smoker, 20 pack-years, and consumes alcohol socially. Past medical history includes controlled hypertension and type 2 diabetes mellitus, diagnosed 5 years ago. No prior malignancies or surgeries. Patient denies any history of deep vein thrombosis or pulmonary embolism. Current medications include Ramipril 5mg daily and Metformin 500mg twice daily. Recent imaging includes a chest CT scan (dated 25 October 2024) showing a 3.5 cm spiculated mass in the right upper lobe with mediastinal lymphadenopathy. No prior biopsies. Latest laboratory tests (dated 28 October 2024) show elevated CRP (15 mg/L) and normal full blood count and liver function tests. Examination: General examination reveals a thin adult male, appearing pale but not acutely distressed. Performance status ECOG 1. Chest auscultation notes decreased air entry in the right upper lobe with occasional crackles. No palpable supraclavicular or axillary lymphadenopathy. Abdominal examination is unremarkable. No peripheral oedema. Vitals are stable. Investigations: Review of chest CT scan (dated 25 October 2024) confirms a 3.5 cm spiculated mass in the right upper lobe, highly suspicious for malignancy. Multiple enlarged mediastinal lymph nodes (largest 1.8 cm) are noted. No distant metastases identified on initial imaging. No prior tumour markers available for review. Staging investigations are incomplete. Assessment: Suspected diagnosis of non-small cell lung carcinoma (NSCLC) in the right upper lobe, likely stage IIIA given the mediastinal lymphadenopathy. Performance status ECOG 1. Risk factors include significant smoking history and family history of lung cancer. Plan: 1. Further staging with PET-CT scan to exclude distant metastases and provide more comprehensive nodal staging. 2. Referral to the multi-disciplinary team (MDT) meeting for discussion and formulation of a comprehensive treatment strategy. 3. Bronchoscopy with biopsy of the lung mass and EBUS-TBNA of mediastinal lymph nodes for histological confirmation and molecular profiling. 4. Pending MDT discussion, potential treatment intent is curative, with consideration for neoadjuvant chemotherapy followed by surgery or definitive chemoradiation. 5. Follow-up appointment scheduled for 1 November 2024 to discuss PET-CT and biopsy results, and MDT recommendations.