Attending Physician Statement - APS Notes

How long do you believe the symptoms had been present when you were first consulted?: 3 months 1. Diagnosis: The patient has been diagnosed with Stage II breast cancer, characterized by a tumor size of 2-5 cm and spread to nearby lymph nodes. 2. Underlying cause of the patient’s condition: The condition is primarily due to genetic predisposition and hormonal factors, as indicated by family history and elevated estrogen levels. 3. Objective findings supporting the diagnosis and prognosis: Mammography on 15 August 2024 showed a 3.5 cm mass in the left breast. Biopsy on 20 August 2024 confirmed malignancy. MRI on 1 September 2024 indicated lymph node involvement. Date of surgery, if applicable (month/day/year): 10 September 2024 4. Is the patient capable of performing activities of daily living?: No, the patient cannot perform certain activities of daily living due to fatigue and limited mobility. Activities of Daily Living he/she cannot perform: The patient is unable to perform tasks such as cooking, cleaning, and shopping independently. Since when? (month/day/year): 15 September 2024 5. What kind of treatments has the insured received in relation to the condition?: The patient has undergone a lumpectomy, followed by chemotherapy and radiation therapy. Hormonal therapy with Tamoxifen has also been initiated. 6. Were there other treatments/procedures recommended to the insured?: Yes, additional immunotherapy was recommended to enhance treatment efficacy. Since when (month/day/year): 1 October 2024 Expected Recovery (month/day/year): 1 March 2025 7. Did the patient's condition result in any major, permanent neurological deficit that will require physical rehabilitation?: No, there are no major neurological deficits requiring rehabilitation. 8. Has the patient been hospitalized or attended to for any other medical condition?: The patient was hospitalized for pneumonia from 5 July 2024 to 12 July 2024. Past Health History: Name and Addresses of Attending Physician: Dr. Sarah Johnson, 123 Health St, London, UK Date of Consultation: 1 June 2024 Diagnosis: Hypertension Period of Consultation: 1 June 2024 - 30 June 2024 Are you the patient’s regular attending physician?: Yes, I have been managing the patient's care for the past year. 9. Has the patient been referred to other physicians?: Referred to Dr. Emily Brown, Oncologist, for specialized cancer treatment. 10. Does the patient smoke cigarettes/cigarillos/cigars or consume any other tobacco product?: No 11. Additional information relevant to this claim: The patient has shown resilience and a positive response to treatment, which is promising for recovery. Signature Signature of Attending Physician: Dr. Thomas Kelly Printed Name: Kelly, Thomas J. Field of Specialization: Oncology PTR No.: 123456 License No.: 789012 Contact Number/s: +44 20 7946 0958 Email Address: thomas.kelly@healthcareclinic.com Date of Signing (month/day/year): 1 November 2024 Place of Signing: London, UK Clinic Hours: Monday to Friday, 9 AM to 5 PM