sample_patient_notes.csv

,pseudo_mrn,date,text
0,74643,2020-01-01,"**PATHOLOGY REPORT**

---

### Patient Information  
**Name:** David Kim  **Sex/Age:** Male / 47 y/o  

### Specimen Identification  
- **Accession #:** LP‑47321‑BXC  
- **Procedure Date:** [date withheld] – CT‑Guided Percutaneous Core Needle Biopsy  
- **Anatomic Site:** Left Upper Lobe (segment S³⁄⁴), Lung Parenchymal Mass, C34.2  

### Type of Specimen  
Core needle biopsy specimens obtained under computed tomography guidance; 5 dedicated cores placed in formalin.

---  

## Gross Description  

| Item | Quantity | Dimensions (mm) | Appearance |
|------|----------|-----------------|------------|
| Core #1 | 1 | 18 × 2 × 2 | Tan–white, firm, focally hemorrhagic |
| Core #2 | 1 | 16 × 2 × 2 | Tan–white, gritty |
| Core #3 | 1 | 15 × 2 × 2 | Grayish-pink, soft |
| Core #4 | 1 | 13 × 2 × 2 | White, rubbery |
| Core #5 | 1 | 12 × 2 × 2 | Pink-tan, friable |

All cores were inked, bisected longitudinally, submitted entirely in cassettes labeled “LP‑47321‑BX”. Tissue fixed in neutral buffered formalin for ≥24 hours before processing.

---  

## Microscopic Examination  

*Histopathology:* Sections reveal sheets and nests of markedly atypical malignant cells set against a background of desmoplastic stroma and foci of geographic necrosis. Tumor cells display moderate-to-large eosinophilic cytoplasm, vesicular nuclei with coarse clumped chromatin, conspicuous nucleoli (≥2 × size of adjacent lymphocyte nucleus), and frequent abnormal mitoses (>20/10 HPF). Occasional rosette-like arrangements and scant intracytoplasmic granules suggest neuroendocrine differentiation.

*Architectural pattern*: Predominantly solid growth with occasional trabecular formation; absence of glandular/tubular structures excludes adenocarcinoma component. No keratin pearls or squamous maturation observed.

*Margin evaluation*: All margins represented by peripheral fragments of normal alveolar parenchyma; unable to assess true radial margin due to limited sampling inherent to core biopsies.

---  

## Immunohistochemistry & Ancillary Tests  

| Marker | Result | Interpretation |
|--------|--------|----------------|
| Pan‑Cytokeratin (AE1/AE3) | Diffuse strong membranous staining | Confirms epithelial origin |
| Neuroendocrine Markers:<br>- Synaptophysin | Focal (+) in ≈30 % of tumor cells | Supports neuroendocrine phenotype |
| - Chromogranin A | Weak focal (+) | Consistent with neuroendocrine differentiation |
| - CD56 (NCAM) | Positive (moderate) | Reinforces neuroendocrine profile |
| TTF‑1 | Negative | Typical for large‑cell histotype lacking adenocarcinoma lineage |
| Napsin A | Negative | Excludes conventional adenocarcinoma |
| p40/p63 | Negative | Rules out squamous differentiation |
| Ki‑67 (MIB‑1) | Approximately 55 % labeling index (high) | High proliferative activity |
| PD‑L1 (22C3 pharmDx) | Tumor Proportion Score = 10 % (TPS) | Low-level expression |

*Molecular Testing:* None performed on this specimen; subsequent next‑generation sequencing ordered on parallel material (see separate record).

---  

## Diagnostic Summary  

**Primary Diagnosis:**   
Large Cell Carcinoma of the Lung, left upper lobe, exhibiting neuroendocrine features, WHO grade III (high proliferative rate).  

**Additional Comments:**  
- The presence of focal neuroendocrine marker positivity indicates divergent differentiation but does not meet criteria for definitive small‑cell carcinoma.  
- Ki‑67 index of 55 % underscores aggressive biology; however, therapeutic decisions should integrate staging data and molecular profile (KRAS, STK11, etc.) obtained subsequently.  
- PD‑L1 expression measured at 10 % (22C3) suggests modest checkpoint inhibitor targetability; interpretation should consider overall tumor microenvironment and forthcoming systemic options.

---  

**Prepared By:**  
Dr. ***[Pathologist Name], MD***  
Board Certified Anatomic Pathology  

**Report Verified On:** [date withheld]

---  "
1,74643,2020-01-02,"**Next‑Generation Sequencing (NGS) Molecular Profiling Report**

---

### Patient Information  
**Name:** David Kim  **Sex/Age:** Male / 47 y/o  

### Specimen Details  
| Item | Description |
|------|-------------|
| **Specimen ID** | LR-LU‑00123 (Left Upper Lobe Core Biopsy) |
| **Date of Collection** | [date omitted] |
| **Source** | Computed tomography–guided core needle biopsy – left upper lobe pulmonary mass (≈5 cm) |
| **Histology (from accompanying H&E)** | Large‑cell carcinoma with focal neuroendocrine differentiation |

### Test Performed  
*Targeted DNA & RNA hybrid capture panel covering >300 cancer‐relevant genes (including SNVs, indels, copy number alterations, splice site changes, selected gene fusions).*  

Sequencing platform: Illumina NovaSeq 6000  
Average depth of coverage (tumor): ~850×  
Tumor cellularity estimated at 65 %.

### Detected Genomic Alterations  

| Gene | Variant | Allele Frequency* | Interpretation |
|------|---------|-------------------|---------------|
| **KRAS** | c.35G>T (p.Gly12Val) | 38 % | Activating missense mutation typical of driver oncogene in NSCLC. |
| **STK11** | Whole‑gene deletion (loss) inferred from copy‑number analysis | NA | Tumor suppressor loss associated with aggressive phenotype and reduced response to immune checkpoint blockade. |
| **KEAP1** | c.1796_1800del (p.Leu599Serfs*13) | 32 % | Loss‑of‑function frameshift leading to NRF2 pathway activation; linked to resistance to oxidative stress and potentially poorer outcomes. |
| **TP53** | c.658A>G (p.Tyr220Cys) | 41 % | Missense mutation affecting DNA‑binding domain; classic tumor‑suppressor alteration conferring genomic instability. |
| **MET** | Exon 14 skipping transcript detected (low‑level) – junction reads supporting Δex14 | Approx. 5 % (estimated from RNA read count) | In-frame splicing variant resulting in impaired degradation of MET protein; low allelic burden suggests subclonal population. |
| **ALK** | Rearrangement – Not detected (RNA fusion assay negative) | — | No actionable ALK fusion identified. |
| **ROS1** | Rearrangement – Not detected (RNA fusion assay negative) | — | No actionable ROS1 fusion identified. |

\*Allele frequency reflects proportion of mutant reads relative to total reads at the locus (DNA‑based unless otherwise noted).

### Additional Technical Notes  

- **Quality Metrics:** All target regions achieved ≥100× coverage; mean uniformity = 96 %. No evidence of sample contamination.  
- **Microsatellite Instability (MSI):** Stable (no MSI‑high signature observed).  
- **Tumor Mutational Burden (TMB):** Estimated 7 mut/Mb (intermediate range for NSCLC).  

### Interpretative Summary  

The comprehensive profiling of the left upper lobe large‑cell carcinoma reveals:

1. An *activating KRAS G12V* point mutation, establishing KRAS as the principal oncogenic driver. This alteration is known to confer sensitivity to emerging KRAS^G12C inhibitors (e.g., adagrasib, sotorasib) when the cysteine substitution is present; however, G12V does not fall under current FDA‑approved KRAS inhibitor indications, though investigational agents targeting non‑cysteine KRAS mutants exist.

2. Co‑occurrence of **STK11 loss**, **KEAP1 mutation**, and **TP53 Y220C**—a constellation frequently seen in “KP” (KRAS + TP53) or “KL” (KRAS + LKB1/STK11) molecular subsets of lung adenocarcinoma. The presence of STK11 loss and KEAP1 mutation has been correlated with diminished responsiveness to anti‑PD‑(L)1 immunotherapy and more aggressive clinical behavior.

3. Low‑frequency **MET exon 14 skipping** transcripts suggest a minor subclone harboring this alteration. While MET exon 14 skipping is an established actionable target (responsive to MET TKIs such as crizo, tepotinib, savolitinib), the subclonal nature (<10 %) raises uncertainty regarding therapeutic benefit.

4. Absence of **ALK** or **ROS1** rearrangements eliminates eligibility for approved ALK/ROS1 tyrosine kinase inhibitors.

Overall, the molecular landscape underscores KRAS-driven oncogenesis accompanied by additional tumor‑suppressor losses that may influence prognosis and selection of systemic therapy strategies.

### Limitations  

- The detection limit for subclonal alterations approximates 5 %; very low‑abundance events below this threshold could remain undetected.  
- Formal validation of MET exon 14 skipping via orthogonal methods (e.g., RT‑PCR) was not performed due to limited tissue availability.  

### Reporting Physician  

Dr. ***[Molecular Pathology Fellow]*​  
Department of Pathology & Laboratory Medicine  

*(Signature electronically generated)*  



--- 

*End of Report*"
2,74643,2020-01-03,"**PATIENT:** David Kim Sex: Male Age: 47  
**REFERRING PHYSICIAN:** Pulmonology / Oncology Team  

---

### EXAMINATION
**Modality:** Integrated whole‑body **^18F‑FDG Positron Emission Tomography / Computed Tomography (PET/CT)**   
**Protocol Summary:** Patient fasted ≥6 h, blood glucose measured at 92 mg/dL before intravenous administration of 370 MBq (≈10 mCi) ^18F‑FDG. Uptake phase lasted ≈60 min. Low‑dose non‑contrast CT obtained for attenuation correction and anatomical localization, followed by standard‐duration helical PET acquisition from skull base through mid‑thigh. Images reconstructed with iterative algorithm; axial slice thickness 3–5 mm.

**Comparison:** None – this is the baseline pre‑therapy study following recent tissue diagnosis.

---

## FINDINGS  

| Region | Observation |
|--------|-------------|
| **Thorax – Lungs** | • **Left Upper Lobe (segment S¹⁺²):** 5.0 × 4.3 × 4.0 cm irregular soft‑tissue mass centered in the posterior segment. On PET, markedly increased FDG accumulation with **maximum standardized uptake value (SUVₘₐₓ) = 12.0**, heterogeneous internal metabolism, peripheral rim of slightly lower activity likely reflecting necrosis.<br>• **Ipsilateral (left) hilar region (station 10L):** Single enlarged lymph node measuring 1.4 cm short axis, demonstrating focal FDG avidity (**SUVₘₐₓ ≈ 8.5**) concordant with metabolically active nodal disease.<br>• **Contralateral lung fields:** No discrete pulmonary nodules or areas of abnormally increased FDG uptake.<br>• **Pleura:** No pleural thickening or effusion. |
| **Mediastinum & Central Structures** | No additional FDG‑avid mediastinal lymph nodes beyond the aforementioned hilar node. Cardiac silhouette unremarkable. |
| **Upper Abdomen (liver, adrenal glands, pancreas, spleen)** | Normal physiologic hepatic uptake; no focal hypermetabolic foci in liver, bilateral adrenals, pancreas, or spleen. |
| **Lower Abdomen/Pelvis** | Physiologic bowel activity without focal abnormalities. No osseous lesions demonstrably hypermetabolic. |
| **Bone Survey** | No focal skeletal uptake above background suggesting metastatic disease. |
| **Soft Tissue** | Unremarkable musculature and skin. |

*Overall image quality satisfactory.*  

---

## IMPRESSION  

1. **Baseline metabolic characterization** of histologically proven left upper‑lobe large‑cell carcinoma with prominent FDG uptake (**SUVₘₐₓ = 12**), confirming high glycolytic activity typical of aggressive NSCLC.  
2. **Single ipsilateral hilar lymph node** (station 10L) demonstrates significant FDG avidity (**SUVₘₐₓ ≈ 8.5**), supporting clinical N1 classification.  
3. **Absence of FDG‑avid disease** elsewhere (contralateral lung, mediastinum, supraclavicular regions, abdomen, pelvis, skeleton) → no detectable distant metastasis (cM0).  
4. Radiographic staging aligns with **clinical stage IIIA (cT2b N1 M0)** per AJCC 8ᵗʰ edition.  

These findings provide essential baseline data for forthcoming multimodality therapy planning (induction chemoradiation followed by surgery). Continued close imaging surveillance is advised post‑treatment to assess response.  



--- 

**Prepared By:** Dr. _______________________, MD  
Radiology Department – Thoracic Imaging Service  


*(Signature electronic)*"
3,74643,2020-01-04,"**Oncology Consultation Note – Multidisciplinary Tumor Board Recommendation**

---

### Patient Information  
**Name:** David Kim  **Age:** 47  **Sex:** Male  

---  

## Chief Complaint  
Evaluation and management plan for newly diagnosed left‐upper‑lobe non–small cell lung cancer (NSCLC), stage IIIA (cT2b N1 M0), histologically classified as large‑cell carcinoma with neuroendocrine features.

---  

## History of Present Illness  
David Kim is a previously healthy 47‑year‑old man who presented three months ago following an incidentally detected pulmonary opacity on a screening computed tomography (CT) scan obtained for occupational health surveillance. He denies cough, hemoptysis, dyspnea, wheezing, fever, weight loss, night sweats, or chest pain. His performance status is estimated at Eastern Cooperative Oncology Group (ECOG) 0.

Bronchoscopy with CT‑guided core needle biopsy of the left upper lobe (segment 1) yielded a poorly differentiated large‑cell carcinoma exhibiting focal neuroendocrine differentiation. Immunohistochemistry demonstrated synaptophysin positivity in scattered cells. The proliferative index (Ki‑67) was elevated at 55 %; programmed death‑ligand 1 (PD‑L1) expression measured by 22C3 assay was 10 %.

Comprehensive next‑generation sequencing (NGS) performed on the same tissue sample identified:

| Gene | Alteration |
|------|------------|
| **KRAS** | G12V (activating) |
| **STK11** | Loss-of-function |
| **KEAP1** | Missense mutation |
| **TP53** | Y220C missense |
| **MET** | Low‑level exon 14 skipping |

No ALK or ROS1 rearrangements were detected. Fluorescence in situ hybridization (FISH) for EGFR amplification was negative.

Staging work‑up consisted of contrast‑enhanced chest CT demonstrating a 5.0 × 4.5 cm spiculated mass involving the posterior segment of the left upper lobe with associated atelectasis, and a solitary enlarged ipsilateral hilar lymph node measuring 1.8 cm. No additional intrathoracic adenopathy was visualized. Whole‑body ^18F‑FDG PET/CT disclosed intense metabolic activity confined to the primary lesion (SUV_max = 12) and the involved hilar node (SUV_max ≈ 8). Brain MRI was unremarkable. Overall staging is cT2b N1 M0 → stage III​A (AJCC 8th edition).

He has never smoked cigarettes (never‑smoker), works as a software engineer, lives with his spouse, and drinks socially (<2 drinks/week). There is no personal or familial history of malignancy aside from a paternal uncle with colorectal cancer diagnosed at age 68.

---  

## Review of Systems  
*General:* Denies fevers, chills, recent infections, unintended weight change.  
*Respiratory:* No chronic cough, sputum production, dyspnea, pleuritic chest pain, or hemoptysis.  
*Cardiovascular:* No palpitations, orthopnea, edema.  
*GI:* Normal appetite, bowel habits regular, no nausea/vomiting.  
*Genitourinary:* No dysuria, frequency changes.  
*Neurologic:* No headaches, dizziness, seizures.  
*Skin:* No rashes or lesions.  
All other systems reviewed and negative.

---  

## Past Medical History  
- Hypertension – well controlled on lisinopril 10 mg daily (diagnosed at age 42).  
- Hyperlipidemia – atorvastatin 20 mg nightly.  
- No known cardiac, hepatic, renal, or hematologic disorders.  

## Surgical History  
Appendectomy (age 23).  

## Social History  
Never smoker, occasional alcohol, no illicit drugs. Lives with wife, employed full‑time, exercises regularly (running 3 times/week).  

## Family History  
Father alive, hypertension; mother deceased (stroke at 78); brother healthy; paternal uncle colon CA at 68.  

## Allergies  
NKDA (no known drug allergies).  

## Current Medications  
- Lisinopril 10 mg PO QD  
- Atorvastatin 20 mg PO HS  
- Vitamin D₃ 2000 IU daily  

---  

## Physical Examination  
**Vital Signs:** BP 122/76 mmHg, HR 72 bpm, RR 16/min, Temp 36.8°C, SpO₂ 98 % RA.  

**General:** Well‑appearing, NAD, alert & oriented ×3.  

**HEENT:** Normocephalic, atraumatic, mucous membranes moist.  

**Neck:** Supple, no cervical adenopathy.  

**Chest/Lungs:** Clear breath sounds bilaterally, no crackles, rhonchi, or egophony. Slight reduction of tactile fremitus over left apex correlates with radiographic abnormality.  

**Heart:** Regular rate/rhythm, S1/S2 audible, no murmurs/gallops.  

**Abdomen:** Soft, nondistended, normoactive bowel sounds, no hepatosplenomegaly.  

**Extremities:** No clubbing, cyanosis, edema.  

**Neurological:** Grossly intact cranial nerves II‑XII, strength 5/5 throughout, sensation preserved.  

---  

## Laboratory Data (most recent, drawn today)

| Test | Result | Reference |
|------|--------|-----------|
| CBC w/diff | WBC 6.2 ×10⁹/L, Hb 13.8 g/dL, Plts 240 ×10⁹/L | Normal |
| Comprehensive Metabolic Panel | Na 138, K 4.2, Cl 102, CO₂ 24, BUN 15, Cr 0.92, Glu 94, AST 21, ALT 19, Alk Phos 71, Total Bilirubin 0.6 | Within limits |
| LDH | 180 U/L | ≤250 |
| CEA | 2.1 ng/mL | ≤5 |
| Serum electrolytes, thyroid panel – pending | — | — |

---  

## Radiology Summary  

**Contrast Chest CT (Axial):** Left upper lobe posterior segment harbors a 5.0 × 4.5 cm irregular soft‑tissue mass causing adjacent bronchial narrowing; internal heterogeneity suggests necrosis. One ipsilateral hilar LN measures 1.8 cm short axis, mildly hyperattenuating. No contralateral hilar or mediastinal nodes >1 cm. No pleural effusion or chest wall invasion.  

**^18F‑FDG PET/CT:** Intense FDG avidity localized to the aforementioned primary lesion (SUV_max = 12) and the left hilar node (SUV_max ≈ 8). No extrathoracic foci of increased metabolism.  

Interpretation aligns with clinically staged cT2b N1 M0 disease.

---  

## Assessment  

1. **Stage III A (cT2b N1 M0) left‑sided large‑cell carcinoma with neuroendocrine features**, harboring KRAS G12V, STK11 loss, KEAP1, TP53 mutations, low‑level MET exon 14 skipping, PD‑L1 ≈10 %.  
   - High‑risk biologic profile (concurrent KRAS/STK11/KEAP1 alterations) predicts modest response to immunotherapy alone.  
   - Molecular landscape does not presently support FDA‑approved targeted agents beyond investigational KRAS inhibitors.  

2. **Overall Health Status:** Excellent functional reserve (ECOG 0), adequate organ function, suitable candidate for multimodality curative intent therapy.

---  

## Plan / Recommendations  

After thorough interdisciplinary discussion among Thoracic Surgery, Radiation Oncology, Pulmonary Medicine, and Medical Oncology, consensus recommends **induction concurrent chemoradiation followed by surgical resection**—the standard approach for fit patients with potentially resectable stage IIIA NSCLC when mediastinal clearance cannot be guaranteed preoperatively.

1. **Radiation Oncology Referral**
   - Initiate simulation for definitive thoracic irradiation targeting the primary tumor and involved hilar station with elective coverage of stations 5–7. Planned dose: **60 Gy in 30 fractions** (2 Gy/fraction).  
   - Discuss volumetric modulated arc therapy (VMAT) vs intensity‑modulated RT (IMRT) to minimize esophageal and heart exposure.

2. **Medical Oncology – Chemotherapy Regimen**
   - Concurrent systemic therapy: **carbo AUC 2 IV weekly** + **Taxol 45 mg/m² IV weekly** administered on days 1, 8, 15, 22, 29 of radiation course. This regimen balances efficacy with tolerability in combined modality settings.  
   - Pre‑medication with dexamethasone, diphenhydramine, and famotidine per institutional protocol to mitigate hypersensitivity reactions.  
   - Baseline labs (CBC, CMP) repeated before each cycle; hold chemotherapy for ANC < 1500/mm³ or platelets < 100 000/mm³.

3. **Supportive Care Measures**
   - Prophylactic antiemetics (ondansetron PRN) and stool softeners (docusate) to reduce GI toxicity.  
   - Nutritional counseling; consider oral cryotherapy during radiation sessions to lessen esophagitis risk.  
   - Encourage continued aerobic exercise; monitor weight and muscle mass.

4. **Pre‑operative Evaluation**
   - Upon completion of chemoradiation (approximately 6‑8 weeks), repeat staging CT/PET to assess radiographic response.  
   - Reassess cardiopulmonary fitness (PFTs, VO₂ max) to confirm operative candidacy.  
   - Schedule video‑assisted thoracoscopic surgery (VATS) left upper lobectomy with systematic mediastinal lymphadenectomy (stations 5, 6, 7, 10L) contingent upon favorable restaging.

5. **Discussion of Alternatives & Risks**
   - Reviewed alternative approaches including definitive chemoradiation without surgery versus upfront surgery followed by adjuvant therapy. Emphasized higher local control rates and potential survival benefit with trimodal strategy in appropriately selected patients.  
   - Informed consent regarding acute toxicities (esophagitis, pneumonitis, myelosuppression) and late sequelae (fibrosis, reduced pulmonary reserve).  

6. **Clinical Trial Consideration**
   - Offered referral to ongoing trials evaluating KRAS G12C/G12V selective inhibitors in combination with immune checkpoint blockade; patient expressed interest but prefers standard of care at this juncture.

7. **Follow‑Up Timeline**
   - Weekly visits during chemoradiation for symptom assessment, toxicity grading (CTCAE v5.0), and laboratory monitoring.  
   - Post‑chemoradiation reassessment appointment scheduled 4 weeks after completing radiation to finalize surgical timing.  
   - Ongoing survivorship education concerning smoking avoidance, vaccination updates (influenza, COVID‑19, pneumococcal), and psychosocial resources.

**Signature:** _________________________  
Dr. [Oncologist Name], MD  
Board Certified Medical Oncologist  
Date: *(to be inserted)*"
4,74643,2020-01-05,"**Oncology Progress Note – Follow‑Up After Definitive Chemoradiation**

**Patient:** David Kim  
**MRN:** [redacted]  
**DOB:** **[age 49]**  
**Date:** *[to be inserted]*  

---

### Chief Complaint
Routine interval follow‑up; review of post‑chemoradiation CT chest obtained today.

### History of Present Illness
David is a 49‑year‑old man who was diagnosed at age 47 with stage IIIA (cT2b N1 M0) large‑cell carcinoma of the left upper lobe (LU​L). He completed concurrent chemoradiotherapy 6 weeks ago consisting of weekly carboplatin AUC 2 + paclitaxel 45 mg/m² together with 60 Gy in 30 fractions delivered via IMRT. During treatment he experienced Grade 2 esophagitis (managed conservatively with topical lidocaine slurry and dietary modification) and Grade 3 thrombocytopenia (platelets nadir 62 × 10⁹/L, required a brief transfusion course). Both toxicities fully resolved by week 4 post‑CRT.

He presents today for review of the most recent contrast‑enhanced CT chest performed 2 weeks after completion of CRT. The scan demonstrates marked shrinkage of the LU​L mass from 5.0 cm to 2.8 cm (longest axial dimension) with central cavitation suggestive of necrosis. The previously avid ipsilateral hilar node (station 10L) is no longer visualized. No new parenchymal lesions, pleural effusions, or mediastinal adenopathy are seen. Radiographically this meets criteria for a Partial Response (PR) per RECIST 1.1.

He denies cough, dyspnea, hemoptysis, dysphagia, fevers, chills, weight change, or night sweats since finishing RT. His performance status remains ECOG 0. He feels “back to baseline” aside from occasional mild throat soreness that has improved.

### Review of Systems
| System | Positive / Negative |
|--------|----------------------|
| Constitutional | Denies fever, chills, unexplained weight loss |
| Respiratory | No cough, sputum, dyspnea, wheeze |
| Cardiovascular | No chest pain, palpitations |
| GI | No nausea/vomiting, bowel habits regular |
| GU | No dysuria, frequency |
| Neurologic | No headache, dizziness |
| Dermatologic | No rash |
| Endocrine | No polyuria/polydipsia |

### Past Medical History *(selected)*
- Large‑cell lung carcinoma, left upper lobe, diagnosed 24 months ago  
- Hypertension, well controlled on lisinopril 20 mg daily  
- Hyperlipidemia, on atorvastatin 40 mg nightly  

### Surgical History
Appendectomy (childhood)

### Social History
Never smoker (never >100 cigarettes lifetime). Occasional alcohol (<2 drinks/week). Works as software engineer; physically active (jogging 3–4 times/wk). Lives with spouse; no illicit drugs.

### Family History
Father died of myocardial infarction at 68. Mother alive, hypertension. No known familial cancers.

### Allergies
No drug allergies documented.

### Medications
- Lisinopril 20 mg PO QD  
- Atorvastatin 40 mg PO HS  
- Vitamin D₃ 2000 IU PO Daily  

*(Chemotherapy agents discontinued after last dose 6 weeks ago.)*

### Physical Examination
Vital signs: BP 122/78 mmHg, HR 72 bpm, RR 14/min, SpO₂ 98% RA, Temp 36.8°C.  
General: Well‑appearing, NAD, alert, oriented ×3.  
HEENT: Oropharynx clear, mild erythema of posterior pharyngeal wall (no ulceration).  
Neck: Supple, no cervical LAD.  
Cardiovascular: Regular rate/rhythm, S1/S2 audible, no murmurs.  
Respiratory: Clear breath sounds bilaterally, no rales or wheezes.  
Abdomen: Soft, non‑tender, normoactive BS.  
Extremities: No edema, pulses intact.  
Neurological: Grossly intact cranial nerves, strength 5/5 UE/LE, sensation preserved.  

### Laboratory Data (drawn 3 days ago)
| Test | Result | Reference |
|------|--------|-----------|
| CBC w/diff | WBC 6.2 × 10³/µL, Hb 13.8 g/dL, Plts 210 × 10⁹/L | Normal |
| CMP | Na 138, K 4.2, Cl 102, CO₂ 25, BUN 15, Cr 0.92, AST 32, ALT 35, Alk Phos 88 | Within limits |
| LDH | 180 U/L (nl ≤250) |
| CEA | 2.1 ng/mL (nl <5) |
| Serum electrolytes & glucose – unremarkable |

*Prior labs during CRT reflected transient cytopenias; values have normalized.*

### Imaging Results (Contrast‑Enhanced Chest CT, 2 wks post‑CRT)
- **Primary Lesion (Left Upper Lobe):** Residual solid component measuring 2.8 cm (previous 5.0 cm). Central low attenuation suggests necrotic cavity. Margins smooth, without spiculations.
- **Hilar Nodes:** Station 10L node absent; no other enlarged mediastinal stations (5, 6, 7 negative).
- **Pleura:** No effusion or thickening.
- **Other Lung Parenchyma:** No additional nodules or infiltrates.
- **Upper Abdomen:** Unchanged hepatic steatosis; spleen normal.

Interpretation: Marked volumetric regression compatible with favorable biologic response to combined modality therapy. No evidence of progression.

### Assessment
1. **Stage IIIA large‑cell carcinoma of left upper lobe**, cT2b N1 M0 → now post‑CRT PR, pending pathological staging. Molecular profile: KRAS G12V, STK11 loss, KEAP1 mut, TP53 Y220C, low‑level METex14 skip; PD‑L1 10%.  
   - Current disease burden markedly reduced; patient maintains excellent functional reserve (ECOG 0, PFTs pending).  
2. **Treatment‑related toxicities:** Resolved Grade 2 esophagitis, resolved Grade 3 thrombocytopenia. No ongoing sequelae.  
3. **Hypertension, hyperlipidemia** – stable on current regimen.

### Plan
1. **Surgical Management**
   - Proceed with curative intent left upper lobectomy with systematic mediastinal lymphadenectomy (stations 5, 6, 7, 10L) once pre‑operative work‑up cleared.
   - Order Pulmonary Function Tests (spirometry, DLCO) within the next week; target FEV1 ≥80% predicted and DLCO ≥70%.
   - Cardiac clearance (EKG ± stress test) due to age >45 despite lack of cardiac symptoms.
   - Discuss operative timing with Thoracic Surgery—target operation ∼4–6 weeks post‑CRT to allow tissue recovery while avoiding undue delay.

2. **Adjuvant Considerations**
   - Given complete metabolic response and absence of nodal disease on imaging, adjuvant chemotherapy is not planned unless intra‑operative pathology reveals unexpected residual disease (>pT2a or nodal positivity).  
   - Continue close surveillance per NCCN guidelines: CT chest q3–4 mo for the first year post‑resection.

3. **Supportive Care**
   - Reinforce nutrition counseling; encourage protein‑rich diet to aid wound healing.
   - Prescribe oral rinses (chlorhexidine gluconate) prophylactically for potential post‑op mucosal irritation.
   - Encourage continued aerobic activity as tolerated; avoid heavy lifting >10 lb for 4 wk post‑op.

4. **Follow‑up Labs**
   - Repeat CBC/CMP 1 week prior to scheduled surgery to confirm hematologic adequacy.
   - Monitor fasting lipid panel annually; blood pressure check at each visit.

5. **Education & Counseling**
   - Reviewed expected peri‑operative course, risks (bleeding, air leak, infection) and benefits of achieving R0 resection.
   - Emphasized importance of smoking abstinence (patient never smoked) and avoidance of vaping/e-cigarettes.
   - Provided printed material regarding postoperative pulmonary rehabilitation.

**Next Appointment:** Return in 2 weeks for PFT results and pre‑operative clearance documentation. Contact office sooner if new respiratory symptoms develop.

--- 

*Prepared by:* Dr. ***[Name], MD***  
Medical Oncology – Thoracic Malignancies  
Signature: ______________________   Date: ____________"
5,74643,2020-01-06,"**Oncology Progress Note – Post‑Operative Follow‑Up**

**Patient:** David Kim  
**MRN:** [redacted]  
**DOB:** [redacted]  

---

### CHIEF COMPLAINT
Routine postoperative evaluation following left upper lobectomy with mediastinal lymphadenectomy for previously diagnosed large‑cell carcinoma of the left upper lobe.

---

### HISTORY OF PRESENT ILLNESS
David is a 49‑year‑old man who presents today for his first postoperative oncology appointment approximately **four weeks** after undergoing a left upper lobectomy with systematic mediastinal LN dissection (stations 5, 6, 7, 10L). He recovered uneventfully from surgery, reporting minimal incisional discomfort controlled with acetaminophen PRN. No dyspnea, cough, hemoptysis, chest pain, dysphagia, or constitutional symptoms were endorsed. His performance status remains excellent (ECOG 0). 

He completed definitive concurrent chemoradiotherapy twelve months ago consisting of weekly carboplatin (AUC 2) and paclitaxel (45 mg/m²) combined with 60 Gy in 30 fractions. During that course he experienced grade 2 esophagitis and transient grade 3 thrombocytopenia, both resolved without sequelae. Pre‑surgical staging PET/CT documented a solitary left upper lobe mass (≈5 cm) with a single ipsilateral hilar node, staged clinically as cIII‑A (cT2b N1 M0). The operative pathology disclosed a residual focus of large‑cell carcinoma measuring 1.9 cm, negative radial margins (R0), and **no metastatic involvement in 12 examined mediastinal nodes** (ypT1b N0). Molecular profiling of the original biopsy had shown KRAS G12V, STK11 loss, KEAP1 mutation, TP53 Y220C, and low‑level MET exon 14 skipping; PD‑L1 expression was 10 %.

Given the absence of viable nodal disease, clear margins, and limited residual tumor size, the multidisciplinary team elected close radiographic surveillance rather than immediate adjuvant systemic therapy.

---

### REVIEW OF SYSTEMS
| System | Positive / Negative |
|--------|----------------------|
| Constitutional | Denies fever, chills, night sweats, weight change |
| Respiratory | No cough, sputum production, dyspnea, wheezing |
| Cardiovascular | No chest pressure, palpitations, edema |
| Gastrointestinal | Normal appetite, denies nausea/vomiting, abdominal pain |
| Genitourinary | No dysuria, frequency, hematuria |
| Neurologic | No headache, dizziness, focal deficits |
| Musculoskeletal | No myalgias, arthralgias |
| Dermatologic | No rash, pruritus |
| Endocrine | No polyuria/polydipsia |

Overall ROS unremarkable.

---

### PAST MEDICAL HISTORY
* Non–small cell lung cancer – Large‑cell carcinoma, left upper lobe, Stage IIIA (treated with CRT → lobectomy)
* Hypertension, well controlled on lisinopril 20 mg daily
* Hyperlipidemia, on atorvastatin 40 mg nightly
* Seasonal allergic rhinitis

### SURGERY
Left upper lobectomy with mediastinal lymph node dissection (stations 5, 6, 7, 10L) – 04/XX/XXXX (date omitted per protocol)

### SOCIAL HISTORY
* Former smoker: 15 pack‑years, quit 2 years ago
* Occasional alcohol (≤2 drinks/week)
* Lives with spouse, employed full‑time as software engineer
* Exercise: walks briskly 30 min most days

### FAMILY HISTORY
* Father deceased at 68 from myocardial infarction
* Mother alive, hypertension
* No known familial cancers

### ALLERGIES
* NKDA (No Known Drug Allergies)

### CURRENT MEDICATIONS
| Medication | Dose & Frequency |
|------------|------------------|
| Lisinopril | 20 mg PO QD |
| Atorvastatin | 40 mg PO HS |
| Acetaminophen (PRN incision pain) | 500 mg q6h PRN |
| Multivitamin | Daily |

---

### PHYSICAL EXAMINATION
Vital signs: BP 122/78 mmHg, HR 72 bpm, RR 14/min, Temp 36.8°C, SpO₂ 98% RA.  
General: Well‑appearing, NAD, alert, oriented ×3.  
HEENT: Normocephalic, atraumatic; oral mucosa moist, no thrush.  
Neck: Supple, no cervical adenopathy.  
Cardiovascular: Regular rate/rhythm, S₁/S₂ audible, no murmurs.  
Respiratory: Clear breath sounds bilaterally, faint scar over left posterior axilla, no rales or wheezes.  
Abdomen: Soft, non‑tender, normoactive bowel sounds.  
Extremities: No clubbing, cyanosis, edema.  
Neurological: Grossly intact cranial nerves II‑XII, strength 5/5 throughout, sensation preserved.  

---

### LABORATORY RESULTS *(drawn today)*
| Test | Result | Reference |
|------|--------|-----------|
| CBC w/diff | WBC 6.2 ×10⁹/L, Hb 13.8 g/dL, Plt 210 ×10⁹/L | Normal |
| Comprehensive Metabolic Panel | Na 138 mmol/L, K 4.2 mmol/L, Cl 102 mmol/L, BUN 16 mg/dL, Cr 0.92 mg/dL, AST 24 U/L, ALT 27 U/L, Alk Phos 84 U/L, Total Bilirubin 0.6 mg/dL | Within limits |
| LDH | 165 U/L (nl ≤250) | nl |
| CEA | 1.8 ng/mL (nl ≤5) | nl |
| Serum glucose fasting | 96 mg/dL | nl |

All values within expected ranges; no evidence of cytopenias or hepatic dysfunction.

---

### IMAGING RESULT SUMMARY
Post‑operative contrast‑enhanced chest CT obtained 3 weeks post‑lobectomy (reviewed):  
• Surgical bed demonstrates expected postsurgical changes with linear scarring; no residual soft tissue density.  
• Mediastinum: No enlarged lymph nodes; stations sampled remain unchanged.  
• No pleural effusion or pneumothorax.  
Impression: Complete macroscopic resection (R0) with no detectable residual disease.

---

### ASSESSMENT
1. **Large‑cell carcinoma of left upper lobe – Status post neoadjuvant chemoradiation and curative‑intent left upper lobectomy (ypT1b N0, R0)**  
   - Pathology confirms negative margins and zero involved nodes.  
   - Current imaging reveals no residual tumor.  
   - Given favorable pathological response, observation is appropriate.

2. **Hypertension**, well controlled.  
3. **Hyperlipidemia**, stable on statin.  

---

### PLAN
1. **Surveillance Strategy**
   * Chest CT with IV contrast every **3 months** for the next year, then spacing to **every 6 months** through Year 3, thereafter annually per NCCN guidelines for surgically resected NSCLC.
   * Consider low‑dose screening CT annually beyond Year 3 if smoking history warrants continued vigilance.

2. **Laboratory Monitoring**
   * Repeat CBC/CMP concurrently with imaging visits to detect early hematologic/hepatic toxicity—though none anticipated absent systemic therapy.
   * Lipid panel and blood pressure check at each office visit.

3. **Vaccinations & Preventive Care**
   * Annual influenza vaccine; COVID‑19 booster per CDC guidance.
   * Pneumococcal vaccination series up to date (PCV13 + PPSV23).

4. **Lifestyle Counseling**
   * Continue abstinence from tobacco; reinforce benefits of remaining smoke‑free.
   * Maintain regular aerobic activity (>150 minutes moderate intensity per week) and balanced diet.

5. **Adjuvant Therapy Discussion**
   * Reviewed rationale for observation versus adjuvant chemotherapy/immunotherapy. Consensus: Observation favored due to lack of nodal disease, negative margins, and adequate recovery from prior chemoradiation. Patient agrees.

6. **Follow‑up Appointment**
   * Return to clinic in **3 months** for interval review and coordination of upcoming CT scan.

7. **Documentation**
   * All pathology slides archived; molecular profile retained for potential future therapeutic decision‑making (KRAS G12V, STK11 loss, KEAP1 mutant, TP53 Y220C). Will reassess eligibility for emerging KRAS inhibitors should recurrence occur.

**Signature:** ___________________________  
Dr. ***[Name], MD*** — Medical Oncology  
Date: _____________ (to be auto‑populated)"
6,74643,2020-01-07,"**Imaging Report – Chest Computed Tomography**

---

**Patient:** David Kim  
**Sex/Age:** Male / 50 years  

**Study Requested By:** Oncology Service – Surveillance Imaging  

**Exam Performed:** Multidetector computed tomography (MDCT) of the chest, intravenous iodinated contrast administered (unless contraindicated), axial images obtained with ≤1 mm slice thickness, reconstructed in coronal and sagittal planes. Standard lung window and soft‑tissue (mediastinal) window settings applied.  

**Comparison:** Prior postoperative surveillance CT dated approximately 12 months earlier (post‑lobectomy, age 49).

---

### FINDINGS

#### **Pulmonary Parenchyma**
- Right Lung: No focal consolidations, ground‑glass opacities, cavitary lesions, or solid nodules identified. Airway patency preserved throughout segmental bronchi. No bronchial wall thickening.
- Left Lung (post‑left upper lobectomy): Surgical changes evident with complete removal of the left upper lobe. Post‑operative fibrosis and staple lines visualized without associated fluid collections. Residual left lower lobe appears aerated and free of discrete masses. No parenchymal scarring extending into adjacent segments.
- No new pulmonary nodules detected bilaterally. No residual mass related to previously treated left upper lobe lesion.

#### **Mediastinum & Hilar Structures**
- Central airways (trachea, mainstem bronchi) maintain normal caliber; no endobronchial obstruction.
- Mediastinal fat planes intact. Cardiac silhouette within normal limits for body habitus.
- No enlarged mediastinal, prevascular, or paraesophageal lymph nodes. All measured short axes ≤ 8 mm; none demonstrate abnormal enhancement.
- Bilateral hila appear unremarkable; no suspicious hilar adenopathy.

#### **Pleural Spaces**
- No pleural effusions, pneumothorax, or loculated fluid collections observed. Pleural surfaces smooth.

#### **Chest Wall & Upper Abdomen**
- Visualized portions of the ribs, vertebral bodies, and scapulae show normal bone density without destructive lesions or periosteal reaction.
- Subcentimeter calcified granuloma noted in the posterior right costophrenic angle—stable appearance compared with prior examination.
- Liver, adrenal glands, and spleen partially visualized through inferior slices; appear homogeneous with no focal hepatic lesions or adrenal enlargement.

#### **Upper Thoracic Vessels**
- Great vessels patent; no aneurysmal dilatation or intravascular filling defects suggestive of thrombus.

---

### IMPRESSION
1. **No evidence of recurrent or metastatic disease** in the chest. Absence of residual tumor in the operative bed and lack of new pulmonary nodules or mediastinal/hilar lymphadenopathy.
2. Postsurgical changes secondary to left upper lobectomy with expected postoperative anatomy; unchanged from prior imaging.
3. Incidental small calcified granuloma in the right posteroinferior costophrenic region—stable.
4. Overall chest CT demonstrates normal thoracic structures without acute abnormalities.

*Recommendation:* Continue routine oncology surveillance per institutional protocol. No immediate further imaging required at this interval."
7,74643,2020-01-08,"**Oncology Follow‑Up Visit Note**  
*Patient:* David Kim *M/D.O.B.:* **[redacted]** *Age:* 51 *Sex:* Male  

---

### Chief Complaint
Routine survivorship/follow‑up appointment. Patient denies any new symptoms.

### History of Present Illness (HPI)
David is a 51‑year‑old man who presents today for his scheduled post‑operative/on‑therapy follow‑up approximately 3 years after definitive management of a stage IIIA left upper‐lobe large‑cell lung carcinoma (ypT1bN0, R0). He reports feeling “well,” with return to baseline activities and exercise tolerance without limitation. Denies cough, dyspnea, wheeze, hemoptysis, chest pain, fever, night sweats, weight change, dysphagia, odynophagia, abdominal discomfort, nausea/vomiting, changes in bowel habits, polyuria/polydipsia, skin rash, neuropathy, or any other constitutional concerns. 

He has been fully recovered from his combined modality therapy (concurrent carbo–PTX + 60 Gy thoracic RT) completed at age 48, followed by left upper‑lobectomy with mediastinal LN dissection at age 49. Post‑surgical pathology documented residual 1.9 cm large‑cell carcinoma, 0/12 nodes involved (ypT1bN0). Surveillance computed tomography of the chest obtained at age 50 demonstrated complete radiographic response with no detectable pulmonary masses or suspicious lymphadenopathy. There have been no intervening systemic therapies since then.

His performance status remains excellent (ECOG 0). He continues to work full‑time as a software engineer, exercises regularly (≈150 min/week moderate cardio), and adheres to a balanced diet. No tobacco use since quitting at age 46; occasional alcohol consumption (<2 drinks per week).

### Review of Systems (ROS)

| System | Positive / Negative |
|--------|----------------------|
| Constitutional | No fevers, chills, night sweats, unexplained weight loss or gain |
| HEENT | No sore throat, hoarseness, sinus congestion |
| Respiratory | No cough, sputum production, dyspnea, pleuritic pain |
| Cardiovascular | No chest pressure, palpitations, edema |
| Gastrointestinal | Normal appetite, no nausea, vomiting, dyspepsia, melena, hematochezia |
| Genitourinary | No dysuria, frequency, nocturia |
| Musculoskeletal | No myalgias, arthralgias, bone pain |
| Neurologic | No headaches, dizziness, peripheral neuropathy |
| Dermatologic | No rashes, pruritus |
| Endocrine | No polydipsia/polyuria, thyroid symptoms |
| Hematologic/Lymphatic | No bruising, bleeding, swollen glands |

Overall ROS is unremarkable.

### Physical Examination

- **Vitals:** BP 122/78 mmHg, HR 68 bpm, RR 14/min, Temp 36.8°C, SpO₂ 98% RA, BMI 26 kg/m².  
- **General:** Well‑appearing, NAD, alert & oriented ×3, ECOG 0.  
- **HEENT:** Normocephalic, atraumatic, mucous membranes moist.  
- **Neck:** Supple, no cervical adenopathy.  
- **Cardiovascular:** Regular rate/rhythm, S₁S₂ audible, no murmurs, rubs, gallops.  
- **Respiratory:** Clear breath sounds bilaterally, no crackles, wheezes, or rhonchi. Surgical scar over left posterior axilla appears healed, no erythema or drainage.  
- **Abdomen:** Soft, non‑distended, normoactive bowel sounds, no hepatosplenomegaly, no tenderness.  
- **Extremities:** No clubbing, cyanosis, edema. Full range of motion, strength 5/5 throughout.  
- **Skin:** Warm, dry, intact; no lesions.  
- **Neurological:** Cranial nerves II‑XII intact, gait steady, sensation preserved.

### Laboratory Results *(drawn today)*

| Test | Result | Reference |
|------|--------|-----------|
| CBC w/diff | WBC 6.2 ×10⁹/L, Hb 13.8 g/dL, Plt 240 ×10⁹/L | All within limits |
| Comprehensive Metabolic Panel | Na 138 mmol/L, K 4.2 mmol/L, Cl 102 mmol/L, CO₂ 24 mmol/L, BUN 15 mg/dL, Cr 0.92 mg/dL, Glucose 94 mg/dL, AST 21 U/L, ALT 19 U/L, Alk Phos 71 U/L, Total Bilirubin 0.6 mg/dL | Unremarkable |
| Lipid panel | LDL 112 mg/dL, HDL 52 mg/dL, TG 115 mg/dL | Acceptable |
| Serum CEA | 1.8 ng/mL (≤5) | Within normal |
| LDH | 180 U/L (125‑250) | Normal |
| Thyroid function (TSH/T4) | TSH 2.1 µIU/mL, Free T4 1.1 ng/dL | Euthyroid |

All values are stable compared with prior assessments.

### Imaging Results

Most recent cross‑sectional imaging: **Chest CT (non‑contrast)** performed 6 months ago (age 50) — *Interpretation*: No residual parenchymal opacity in the left upper lobe operative bed, no new solid/subsolid nodules, mediastinum and hila free of enlarged nodes, no effusions. Radiology impression: “No evidence of recurrent or metastatic disease.” No additional scans ordered at today’s encounter.

### Assessment

1. **Stage‑IIIa (cT2bN1M0) Large Cell Carcinoma of Left Upper Lobe**, treated with definitive CRT → lobectomy (ypT1bN0, R0) – presently **no evidence of disease (NED)**. Ongoing remission >2 yr. Molecular profiling previously disclosed KRAS G12V, STK11 loss, KEAP1 mutation, TP53 Y220C, low‑level MET exon‑14 skip; no actionable EGFR, ALK, ROS1 alterations. Current disease‑free interval supports continuation of standard surveillance rather than adjuvant systemic therapy.

2. **Performance status/ECOG 0**, fully functional, no treatment‑related sequelae.

3. **Preventive health** – Up‑to‑date immunizations (influenza annually, COVID‑19 booster series, pneumococcal PCV20 administered at age 49). Screening colonoscopy due at age 55 (patient plans accordingly). Low cardiovascular risk; lipid profile modestly elevated LDL—continue dietary counseling.

### Plan

| Item | Details |
|------|---------|
| **Surveillance Imaging** | Schedule contrast‑enhanced Chest CT in 6 months (approx. age 52) per NCCN guideline for Stage I NSCLC post‑resection. Consider low‑dose CT annual thereafter if interim scans remain negative. |
| **Laboratory Monitoring** | Repeat CBC/CMP and serum CEA concurrently with imaging. Monitor fasting glucose quarterly given emerging data linking KRAS‑mutant tumors and metabolic derangement (though patient currently euglycemic). |
| **Lifestyle Counseling** | Reinforce abstinence from tobacco (maintain quit status). Encourage ≥150 min/week aerobic activity, Mediterranean‑style diet, limit processed red meat. Discuss sun protection and vitamin D supplementation (25‑OH level pending). |
| **Vaccinations** | Ensure seasonal influenza vaccine before fall season; verify tetanus-diphtheria boosters up to date. |
| **Psychosocial Support** | Offer referral to survivorship support group; screen PHQ‑9 (score 2) – no depression. |
| **Future Therapeutic Planning** | Documented KRAS G12V mutation positions him for eligibility in ongoing KRAS‑targeted trials (e.g., adagrasib, combination KRAS inhibitor + SHP2 blockade). Counsel patient that such options will be revisited if recurrence occurs. |
| **Follow‑up Appointment** | Return to clinic in 3 months for symptom check and labs; imaging result discussion to occur at subsequent visit when CT available. |
| **Documentation** | Update EMR problem list to reflect “Post‑lung cancer resection – disease‑free” and “KRAS G12V mutant NSCLC”. Add current medication list (none chronic beyond multivitamin). Record allergy status – NKDA. |

**Signature:** ________________________   Dr. ***[Oncologist Name], MD***   
**Date:** [auto‑generated]   

---"
8,74643,2020-01-09,"**Imaging Report – Computed Tomography (Chest)**  

**Patient:** David Kim  
**Sex/Age:** Male / 53 years  
**Referring Physician:** Oncology Service  
**Study Date:** [Date omitted per protocol]  
**Accession #:** _______________________  

---

### TECHNIQUE
Multidetector computed tomography of the chest was performed without intravenous contrast due to renal function considerations. Axial images were obtained from the lung apices through the adrenal glands with ≤1 mm collimation and reconstructed in standard soft‐tissue (width 400 HU, level 40 HU) and high‑frequency lung kernels (width −600 HU, level −100 HU). Sagittal and coronal multiplanar reformats were generated for anatomic correlation. No motion artifacts compromising image quality were observed.

Comparison made to prior imaging:

* Baseline staging CT (age 47) showing a 5.0 cm left upper lobe mass with ipsilateral hilar adenopathy.  
* Post‑induction chemoradiation CT (age 49) demonstrating reduction to 2.8 cm.  
* Surveillance CTs at ages 50–52 documenting complete response following left upper lobectomy (R0, ypT1bN0).  

---

### FINDINGS  

#### **Pulmonary Parenchyma**
- **Right Middle Lobe:** There is a solitary, partially solid pulmonary nodule measuring *approximately 1.2 × 1.0 cm* (long axis × short axis) located centrally within the posterior segment. The lesion demonstrates mixed attenuation with a peripheral ground‑glass halo surrounding a central higher‑density focus suggestive of a solid component comprising roughly 35 % of the total volume. Margins are mildly irregular but there is no definitive spiculation or cavitation. No associated bronchovascular distortion is evident. This represents a newly detected abnormality when compared with the most recent surveillance CT (age 52), where no such nodule was visualized.

- **Left Lung:** Status post left upper lobectomy with surgical changes including staple lines and fibrosis along the resection margin. No residual parenchymal masses or consolidations. Scarring appears stable relative to prior examinations.

- **Other Lobes:** Right upper and lower lobes, as well as remaining left lung fields, demonstrate normal aeration without additional focal opacities, infiltrates, or cystic change.

#### **Mediastinum & Hila**
- Central airways are patent. No endobronchial lesions identified.
- Mediastinal fat planes preserved. No enlarged mediastinal, prevascular, or para‑aortic lymph nodes (>1 cm short-axis). Bilateral hila appear unremarkable; no evidence of recurrent hilar adenopathy.

#### **Pleural Space**
- No pleural effusion, thickening, or plaques. Surgical clips noted adjacent to left hemithorax correlating with prior lobectomy.

#### **Osseous Structures**
- Visualized ribs, vertebrae, scapulae, and clavicles show no destructive lesions, cortical disruption, or suspicious sclerosis.

#### **Upper Abdomen (included portion)**
- Upper abdominal cuts reveal normal-sized adrenals without enlargement or heterogeneity. No hepatic or splenic lesions appreciably seen within limited field-of-view.

#### **Incidental Findings**
- Small (<5 mm) calcified granuloma in the right lower lobe, unchanged from prior exams—stable benign appearance.
- Mildly increased bibasilar subsegmental atelectasis likely secondary to shallow breathing; otherwise lungs clear.

---

### IMPRESSION
1. New 1.2 cm partly solid (mixed ground‑glass/solid) nodule in the right middle lobe, absent on prior imaging → concerning for early metastatic recurrence versus second primary lung neoplasm in the setting of known KRAS‑mutant large‑cell carcinoma. Correlation with prior imaging timeline and consideration for tissue sampling recommended.

2. Stable post‑lobectomy left lung with no residual or recurrent disease.

3. No mediastinal/hilar lymphadenopathy, pleural effusion, or osseous metastases identified.

4. Incidental small calcified granuloma unchanged; clinically insignificant.

--- 

**Prepared By:** ___________________________________  
Board‑Certified Radiologist, MD  
[Institution Name]  

*(Signature withheld per documentation policy)*  "
9,74643,2020-01-10,"**Oncology Progress Note – Follow‑Up Visit**

---

### Patient  
**Name:** David Kim **MRN:** ██████ **DOB:** ████‑██‑██ **Age:** 54 **Sex:** Male  

### Date of Service  
[Date omitted – to be inserted electronically]

---  

## Chief Complaint  
Routine follow‑up after 8 weeks of sotorasib therapy for recurrent KRAS‑mutant non‑small cell lung cancer (right middle lobe lesion).

## History of Present Illness  
David presents today for his scheduled interval assessment following initiation of sotorasib 960 mg PO QD eight weeks ago for a solitary right‑middle‑lobe subsolid nodule (initial size 1.2 cm) detected on surveillance chest CT at age 53. At the start of therapy he experienced Grade 2 watery diarrhea lasting approximately 5 days, managed conservatively with loperamide and fluid replacement, and Grade 1 transaminase elevation (AST 52 U/L, ALT 61 U/L) that peaked at week 4 and subsequently returned to baseline. He denied recurrence of diarrheal symptoms since week 5, reports normal bowel habits, and feels “generally well.” No fevers, chills, cough, dyspnea, chest pain, weight change, or neurologic complaints were noted. His performance status remains ECOG 0.

He continues sotorasib uninterrupted and denies missed doses. Current concerns focus on reassurance regarding radiographic response and discussion of continued safety monitoring.

## Review of Systems *(pertinent positives & negatives)*  

| System | Positive / Negative |
|--------|----------------------|
| Constitutional | Denies fever, night sweats, recent weight loss or gain |
| Respiratory | No cough, sputum production, hemoptysis, dyspnea, wheeze |
| Cardiovascular | No chest pain, palpitations, edema |
| Gastrointestinal | Diarrhea resolved; occasional mild nausea, no vomiting |
| Hepatic/Biliary | No abdominal pain, jaundice; liver enzymes normalized |
| Endocrine | No polyuria/polydipsia; fasting glucose last month 98 mg/dL |
| Musculoskeletal | No myalgias or arthralgias |
| Neurologic | No headaches, dizziness, neuropathy |
| Dermatologic | No rash or skin changes |

## Past Medical History  

* **Non–Small Cell Lung Cancer**, Large‑cell histology, KRAS G12V mutant, Stage IIIA at presentation (left upper lobe) → definitive chemoradiation + lobectomy → disease‐free until year 53 when isolated contralateral subsolid nodule appeared.  
* Hypertension – controlled on lisinopril 20 mg daily.  
* Hyperlipidemia – rosuvastatin 10 mg nightly.  

## Surgical History  

* Left upper lobectomy with mediastinal LN dissection (ypT1bN0) – age 49, uncomplicated recovery.

## Family History  

* Father died of myocardial infarction at 68.  
* Mother alive, hypertension.  
* No known familial cancers.

## Social History  

* Former smoker, 15 pack‑years, quit at age 46.  
* Occasional alcohol (≤2 drinks/week).  
* Works as software engineer; sedentary desk work.  
* Lives with spouse; no illicit drugs.

## Allergies  

* NKDA (no known drug allergies)

## Medications  

| Medication | Dose/Frequency | Indication |
|------------|---------------|-----------|
| Sotorasib (Lumakras®) | 960 mg PO qd | KRAS‑mutant NSCLC |
| Lisinopril | 20 mg PO qd | HTN |
| Rosuvastatin | 10 mg PO hs | Dyslipidemia |
| Vitamin D₃ | 2000 IU PO qd | Supplement |
| Multivitamin | Daily | General health |

*(Patient uses over‑the‑counter antidiarrheals PRN.)*

## Physical Examination  

| Parameter | Finding |
|----------|---------|
| Vital signs | BP 122/78 mmHg, HR 72 bpm, RR 16/min, Temp 36.8°C, SpO₂ 97% RA |
| General | Well‑appearing, NAD, alert ×3 |
| HEENT | Normocephalic, mucous membranes moist |
| Neck | Supple, no cervical adenopathy |
| Cardiac | Regular rate/rhythm, no murmurs |
| Pulmonary | Clear breath sounds bilaterally, no rales/wheezes |
| Abdomen | Soft, nondistended, normoactive BS, no hepatosplenomegaly |
| Extremities | No edema, pulses intact |
| Skin | Warm, dry, no rash |
| Neuro | Grossly intact cranial nerves, strength 5/5 UE/LE, sensation preserved |

## Laboratory Data (drawn today)  

| Test | Result | Reference |
|------|-------|-----------|
| CBC w diff | WBC 6.2 ×10⁹/L, Hb 13.8 g/dL, Plt 210 ×10⁹/L | Normal |
| Comprehensive Metabolic Panel | Na 138, K 4.2, Cl 102, CO₂ 24, BUN 14, Cr 0.92, Glucose 96 mg/dL, AST 31 U/L, ALT 35 U/L, Alk Phos 84 U/L, Total Bilirubin 0.6 mg/dL | Within limits |
| Lipid panel | LDL 95 mg/dL, HDL 52 mg/dL, TG 115 mg/dL | Stable |
| Serum CEA | 2.1 ng/mL (previous 2.3 ng/mL) | Low/normal |
| Urinalysis | Neg for protein/glucose/blood | Unremarkable |

All values reflect stability compared with pre‑therapy baselines; hepatic enzymes remain ≤Grade 1.

## Imaging Results  

**Chest CT (non‑contrast, thin slice)** – Performed 8 weeks after starting sotorasib:

* Right middle lobe subsolid nodule measured **0.6 cm** (long axis), previously 1.2 cm. Morphologically unchanged except for slight attenuation increase suggestive of fibrosis/reduction in cellularity. No cavitation.
* No additional pulmonary nodules, consolidations, pleural effusion, or atelectasis.
* Mediastinum: No enlarged stations; largest short-axis dimension 5 mm (stable vs prior).
* Upper abdomen visualized incidentally – unremarkable.

Interpretation: **Partial response** according to RECIST v1.1 criteria (≥30% reduction in longest diameter). Radiologist comment: “Findings compatible with therapeutic effect; continue close imaging surveillance.”

## Assessment  

1. **Recurrent KRAS‑G12V mutated NSCLC, right middle lobe subsolid nodule** – Currently demonstrating radiographic partial response to sotorasib after 8 weeks of therapy. Clinically asymptomatic, ECOG 0.  
2. **Treatment‑related toxicities** – Prior Grade 2 diarrhea and transient Grade 1 transaminitis have resolved; no active adverse events presently.  
3. **Hypertension, hyperlipidemia** – Controlled on current regimen.  
4. **Overall functional status** – Excellent; maintains regular employment and exercise.

## Plan  

| Item | Details |
|------|---------|
| **Continue sotorasib** | Maintain Lumakras® 960 mg PO daily. Emphasize adherence; advise patient to contact office promptly if ≥Grade 2 GI upset, persistent elevated LFTs, or unexplained fatigue occurs. |
| **Safety Monitoring** | • CBC, CMP, fasting glucose at next monthly visit.<br>• Liver function tests repeat in 4 weeks (already within Grade 1). |
| **Imaging Surveillance** | Schedule contrast‑enhanced chest CT in 8 weeks (approximately 16 weeks total on therapy) to confirm durability of response; thereafter every 12 weeks while on sotorasib unless progression suspected clinically. |
| **Supportive Care** | Continue OTC loperamide PRN for breakthrough loose stools (<3 days). Encourage adequate hydration and balanced diet. |
| **Vaccinations** | Ensure up‑to‑date influenza vaccine (administered annually) and COVID‑19 booster per CDC schedule; no live vaccines while on targeted agent. |
| **Lifestyle Counseling** | Reinforce smoking abstinence, maintain moderate aerobic activity (150 min/week), limit alcohol intake. |
| **Follow‑up Appointment** | Return in 4 weeks for laboratory review and symptom check; sooner if acute issues arise. |
| **Documentation** | Update electronic problem list to reflect “NSCLC – KRAS G12V – Partial Response to sotorasib” and record current toxicity profile as *Resolved*. |

**Signature:** ___________________________  
Dr. _________, MD — Medical Oncology  
(Phone/EHR signature block)  "
10,74643,2020-01-11,"**Imaging Report – Positron Emission Tomography / Computed Tomography (PET/CT)**  

**Patient:** David Kim  **Sex/Age:** Male, 55 years  
**Referring Physician:** Medical Oncology  
**Study Date:** [Date omitted per protocol]  
**Indication:** Surveillance of previously treated right‑middle‑lobe pulmonary nodule (KRAS‑mutant non‑small‑cell lung cancer) following response to sotorasib therapy.  

---

### Technique
Whole‑body ^18F‑FDG PET acquired 60 minutes after intravenous administration of 370 MBq (10 mCi) FDG. Low‑dose helical CT obtained for attenuation correction and anatomical correlation (120 kVp, automated mA modulation, slice thickness 3 mm). Images reconstructed with standard OSEM algorithm; axial, coronal, and sagittal fused datasets reviewed. Prior PET/CT examinations dated at ages 54 and 52 were available for comparative evaluation.

--- 

### Findings  

#### Thorax  
- **Right Middle Lobe Pulmonary Nodule:** Subsolid nodule measuring 0.6 × 0.5 cm (previously 0.6 cm on the most recent scan). Mild FDG avidity observed with maximum standardized uptake value (**SUVmax ≈ 2.3**, compared with SUVmax ≈ 2.5 on the preceding examination). Morphologically unchanged contour, without spiculated margins or cavitation. No associated bronchial obstruction or atelectasis.  
- **Left Lung & Mediastinum:** Post‑lobectomy changes in the left upper lobe with complete fibrosis; no residual soft tissue abnormality. No enlarged mediastinal or hilar lymph nodes; all stations ≤ 6 mm in short axis, physiologic FDG activity.  
- **Pleura & Chest Wall:** Unremarkable; no pleural effusion or thickening.  

#### Upper Abdomen  
- Liver, spleen, adrenal glands, pancreas unremarkable; physiological hepatic and splenic FDG distribution. No focal metabolic abnormalities detected.  

#### Pelvis & Lower Extremities  
- Normal marrow signal intensity throughout vertebral bodies and proximal femora; expected heterogeneous uptake related to age. No osseous lesions identified.  

#### Additional Observations  
- No evidence of metabolically active metastatic disease in bone, brain (limited CT component), or soft tissues.  
- Physiological urinary excretion of tracer noted.  

--- 

### Comparison
Findings are essentially unchanged relative to the PET/CT performed eight weeks earlier (age 54): the right‑mid‑lung nodule remains stable in size and demonstrates persistently low‑grade FDG uptake. There has been no emergence of new FDG‑avid foci elsewhere in the body since baseline staging at age 47.

--- 

### Impression  
1. Stable low‑grade FDG uptake in the right middle‑lobe subsolid nodule (0.6 cm, SUVmax ~ 2.3). Imaging appearance compatible with indeterminate persistent disease versus benign inflammatory change; however, stability over successive scans favors a controlled neoplastic process under current KRAS‑directed therapy (sotorasib).  
2. No new FDG‑avid lesions suggestive of locoregional progression or distant metastasis.  
3. Overall disease burden unchanged; continued close radiographic surveillance recommended in conjunction with ongoing systemic therapy.  

*Prepared by:* _______________________  
Board‑Certified Radiologist, MD  
Nuclear Medicine/Pet Imaging Division  "
11,74643,2020-01-12,"**Oncology Progress Note – Follow‑Up Visit**

---

### Patient Information  
**Name:** David Kim **MRN:** [redacted] **DOB:** [redacted] **Age:** 56 y/o **Sex:** Male  

---  

## Chief Complaint  
“Feeling a little more tired than usual over the last few weeks.”  

---  

## History of Present Illness (HPI)  
David is a 56‑year‑old man who presents for routine follow‑up while on **sotorasib 960 mg PO daily**, started 13 months ago for recurrent KRAS G12V‑mutant non‑small cell lung cancer (NSCLC) involving a right middle‑lobe subsolid nodule. Since initiating therapy he has tolerated treatment reasonably well aside from transient Grade 2 diarrhea and Grade 1 transaminitis early in the course, both of which resolved without dose modification.

Over the preceding month he has noticed *mild generalized fatigue* that does not limit his activities; he continues to perform ADLs independently, walks ≥30 minutes daily, and remains employed full‑time as a software engineer (ECOG performance status = 0). No associated dyspnea, cough, fever, weight change, night sweats, abdominal pain, nausea/vomiting, melena, hematochezia, dysuria, joint pains, rash, or neurologic symptoms. Denies new medication changes, alcohol intake increase, or travel exposures.

He adheres to sotorasib dosing schedule, takes occasional loperamide PRN for loose stools (last used >4 weeks ago), and monitors blood sugars per home glucometer (most readings 90–110 mg/dL). No episodes of hypoglycemia. 

Overall impression: Stable disease on systemic therapy with emerging fatigue likely multifactorial—possible cumulative effect of KRAS inhibitor, subtle anemia of chronic disease, or lifestyle stressors. No evidence of acute toxicity warranting interruption.

---  

## Review of Systems (ROS)  
| System | Positive / Negative |
|--------|---------------------|
| Constitutional | +Fatigue (mild); -Weight loss, -Fever, -Chills |
| HEENT | -Headache, -Vision changes, -Sore throat |
| Cardiovascular | -Chest pain, -Palpitations, -Edema |
| Respiratory | -Dyspnea, -Cough, -Hemoptysis |
| Gastrointestinal | -Nausea/Vomiting, -Diarrhea (resolved), -Abdominal pain |
| Genitourinary | -Dysuria, -Frequency, -No polyuria |
| Musculoskeletal | -Myalgias, -Arthralgias |
| Neurologic | -Weakness, -Sensory deficits |
| Dermatologic | -Rash, -Pruritus |
| Endocrine | -Polyphagia, -Polydipsia (none reported) |
| Hematologic/Lymphatic | -Bleeding/bruising |

---  

## Past Medical History (PMHx)  
- **Stage III​A Large Cell Carcinoma of Left Upper Lobe** (diagnosed age 47) → neoadjuvant carbo/Taxol + 60 Gy RT → left upper lobectomy (ypT1bN0, R0) – completed curative intent, observed thereafter.  
- **Recurrent KRAS G12V‑mutant NSCLC** (right middle‑lobe subsolid nodule detected age 53) → treated with sotorasib since age 53.  
- Hypertension (well controlled on lisinopril 20 mg QD).  
- Hyperlipidemia (atorvastatin 40 mg nightly).  
- Seasonal allergic rhinitis.  

---  

## Surgical & Procedural History  
- Right video‑assisted thoracoscopic wedge resection (biopsy) of right middle‑lobe nodule – pathology confirming persistent large‑cell histology with KRAS G12V, STK11 loss, KEAP1 mutation, TP53 Y220C; PD‑L1 10 %.  
- Left upper lobectomy with mediastinal LN dissection (stations 5, 6, 7, 10L) – R0, 0/12 nodes involved.  

---  

## Social History (SH)  
- Former smoker: 15 pack‑years, quit at age 46 (quit year coincident with initial diagnosis).  
- Alcohol: Occasional wine (<2 drinks/week).  
- Occupation: Software developer, sedentary work environment.  
- Living situation: Lives with spouse; independent ADLs.  
- Exercise: Regular brisk walking 3–4 times/week.  

---  

## Family History (FH)  
- Father deceased at 68 from myocardial infarction (no known malignancy).  
- Mother alive, 80, hypertension.  
- Siblings healthy.  
- No familial cancers reported.  

---  

## Allergies  
- NKDA (No Known Drug Allergies).  

---  

## Current Medications  
| Medication | Dose | Frequency | Indication |
|------------|------|-----------|-------------|
| Sotorasib | 960 mg | PO daily | KRAS‑mutant NSCLC |
| Lisinopril | 20 mg | PO daily | HTN |
| Atorvastatin | 40 mg | PO nightly | Dyslipidemia |
| Vitamin D₃ | 2000 IU | PO daily | Supplement |
| Acetaminophen PRN | 500 mg | q6h prn pain/fever | Symptom control |
| Loperamide PRN | 2 mg | PO up to 4 tabs/day PRN diarrhea | Diarrhea management |

---  

## Physical Examination  
**Vital Signs:** BP 122/78 mmHg, HR 72 bpm regular, RR 16/min, Temp 36.8°C, SpO₂ 98% RA, Weight 84 kg (BMI 27 kg/m²).  

**General:** Alert, oriented ×3, NAD, appears well‑nutrient.  

**HEENT:** Normocephalic, atraumatic; mucous membranes moist; no cervical adenopathy.  

**Neck:** Supple, trachea midline, no JVD.  

**Cardiovascular:** RRR, no murmurs, rubs, gallops. Peripheral pulses intact bilaterally.  

**Respiratory:** Clear breath sounds bilaterally, no wheezes/rhonchi, good expansion.  

**GI:** Soft, nondistended, normoactive bowel sounds, no tenderness.  

**Extremities:** No edema, clubbing absent.  

**Skin:** Warm, dry, no rashes or lesions.  

**Neurological:** Grossly intact cranial nerves II–XII, strength 5/5 UE/LE, sensation preserved, gait steady.  

---  

## Laboratory Data *(drawn today)*  

| Test | Result | Reference Range | Comment |
|------|--------|-----------------|---------|
| CBC w/ diff | WBC 6.2 ×10⁹/L ; Hb 13.2 g/dL ; Hct 39%; Plts 210 ×10⁹/L | WBC 4‑10 ; Hb 13‑17 ; Plts 150‑400 | Mild dip in hemoglobin compared to baseline (previous 13.8 g/dL) — may reflect chronic disease/fatigue. |
| Comprehensive Metabolic Panel | Na 138 mmol/L ; K 4.2 ; Cl 102 ; CO₂ 24 ; BUN 18 ; Cr 0.92 ; Glucose 96 mg/dL ; AST 32 IU/L ; ALT 38 IU/L ; Alk Phos 85 IU/L ; Total Bilirubin 0.6 mg/dL | Within limits | Slight elevation of transaminases versus pre‑therapy baseline (AST/ALT ≤25 IU/L) – stable, no intervention needed. |
| Lipid panel | LDL 112 mg/dL ; HDL 44 mg/dL ; TG 135 mg/dL | Target LDL <130 | Unchanged. |
| Thyroid Stimulating Hormone | 2.1 µU/mL | 0.4‑4.0 | Normal. |
| Fasting Insulin | 8 µU/mL | 2‑25 | Normal. |
| CEA* | 2.1 ng/mL | ≤5.0 | Low, stable trend. |
| CA19‑9 | 12 U/mL | ≤37 | Within range. |

\*Tumor markers drawn for longitudinal tracking; trends remain flat.

---  

## Radiology Summary  

**Most Recent Chest CT (performed 4 weeks ago):** Thin‑slice axial images demonstrate persistence of a solitary right middle‑lobe subsolid nodule measuring **0.62 cm x 0.58 cm** (stable compared with prior measurement of 0.61 cm). No interval development of additional pulmonary nodules, consolidations, pleural effusion, or mediastinal/hilar lymphadenopathy. Lung parenchymal architecture otherwise unremarkable.

**Prior PET/CT (age 55, 6 months earlier):** Showed low‑grade FDG avidity within the aforementioned nodule (SUVmax ≈2.1) with no new foci elsewhere. Correlates with indolent behavior under sotorasib.

Interpretation: Disease remains radiographically stable (RECIST criteria: non‑progressive).

---  

## Assessment  

1. **KRAS G12V‑mutant NSCLC, recurrent, right middle‑lobe subsolid nodule – stable disease** on sotorasib therapy.  
   - Molecular profile includes co‑alterations (STK11 loss, KEAP1 mutation, TP53 Y220C) which confer modest resistance risk but response thus far sustained.  
   - Current imaging demonstrates stability; laboratory parameters acceptable apart from minimal transaminase rise and borderline drop in hemoglobin.  

2. **Treatment‑related fatigue (Grade 1)** – likely multifactorial (chronic therapy exposure, mild anemia, psychosocial factors).  

3. **Hypertension, hyperlipidemia** – controlled on current regimen.  

4. **Preventive health:** Up‑to‑date immunizations (influenza annually, COVID‑19 booster series).  

---  

## Plan  

| Item | Details |
|------|----------|
| **Continue sotorasib** | Maintain 960 mg PO daily. Reinforce adherence. No dose reduction required at this time. |
| **Monitor labs** | Repeat CBC/CMP in 4 weeks; specifically watch hemoglobin trending and hepatic enzymes. Consider iron studies if Hb falls below 12 g/dL. |
| **Manage fatigue** | • Counsel regarding sleep hygiene, balanced nutrition, moderate aerobic activity.<br>• Offer trial of vitamin B12 level check; supplement if deficient.<br>• Discuss possibility of low‑dose methylphenidate if fatigue becomes disabling (shared decision). |
| **Supportive care** | Keep loperamide available PRN; educate patient to contact office if ≥3 watery stools/day lasting >48 hrs. |
| **Imaging follow‑up** | Schedule thin‑slice chest CT in 12 weeks (±2 wks) to reassess nodule size; interim PET/CT reserved for symptomatic progression or significant growth (>20%). |
| **Vaccinations** | Verify influenza vaccine administered; arrange COVID‑19 booster per CDC guidance. |
| **Comorbidity optimization** | Blood pressure target <130/80 mmHg – continue lisinopril; lipid goal LDL <70 mg/dL – discuss intensifying statin if ASCVD risk escalates. |
| **Referral** | None presently; consider referral to cardio‑oncology if hypertensive burden increases secondary to sotorasib (rare). |
| **Next appointment** | Return in 4 weeks for labs review; sooner if new symptoms develop (e.g., worsening fatigue, GI upset, jaundice, shortness of breath). |
| **Documentation** | Updated problem list entered into EMR; consent reaffirmed for continued off‑label KRAS inhibition. |

**Signature:** ___________________________  
Dr. ***[Oncologist Name], MD***  
Medical Oncology Division  
Date: _____________  

---  

*End of Document*"
12,74643,2020-01-13,"**Oncology Follow‑Up Visit – Progress Note**

**Patient:** David Kim **MRN:** ██████ **DOB:** ███─██─██ **Age:** 58 y **Sex:** Male  
**Date of Service:** [to be inserted]  

---

### Chief Complaint
“Just here for my scheduled check‑up.” No acute complaints.

---

### History of Present Illness (HPI)

David is a 58‑year‑old man with a remote history of Stage IIIA left upper‐lobe large‑cell carcinoma (treated with definitive CRT → lobectomy → observation) who subsequently developed a solitary right‑middle‑lobe subsolid nodule at age 53. Molecular profiling disclosed KRAS G12V, prompting initiation of sotorasib 960 mg PO daily (Lumakras®) at age 53. He has been on continuous therapy for **≈5 years**, achieving radiographic partial response (nodule reduced from 1.2 cm → 0.6 cm) and thereafter maintaining stable disease over multiple assessments.

Therapy‑related toxicities have been modest:

* Grade 2 watery diarrhea (managed with dietary modification & loperamide PRN) – resolved by month 3 of therapy.  
* Grade 1 transaminase elevation (AST/ALT ≤2× ULN) – remained static, monitored quarterly.  
* New onset Grade 3 hyperglycemia at age 57 necessitating initiation of basal–bolus insulin (glargine 20 U nightly, lispro sliding scale).

He reports **mild intermittent fatigue** (no impact on ADLs), **well‑controlled blood sugars** on his insulin regimen (fasting BG 110‑130 mg/dL), **no abdominal pain**, **no dysphagia**, and **no dyspnea**. Denies fevers, chills, night sweats, weight change (>2 kg), cough, hemoptysis, or neurologic symptoms.

Overall functional status remains excellent (ECOG 0). He continues to work full‑time as a software engineer and engages in regular aerobic exercise (≥150 min/week).

---

### Review of Systems (ROS)
| System | Positive / Negative |
|--------|----------------------|
| Constitutional | Fatigue (mild); denies fever, chills, weight loss |
| HEENT | No headache, visual changes, sore throat |
| Cardiovascular | No chest pain, palpitations, edema |
| Respiratory | No cough, sputum, dyspnea, wheeze |
| Gastrointestinal | Occasional loose stools (<2/day); no nausea/vomiting, melena, hematochezia |
| Genitourinary | No dysuria, frequency, hematuria |
| Musculoskeletal | No bone pain, arthralgia |
| Neurologic | No weakness, paresthesias, seizures |
| Dermatologic | No rash, pruritus |
| Endocrine | Hyperglycemia controlled on insulin; no polyuria/polydipsia beyond baseline |

---

### Physical Examination
- **General:** Well‑appearing, NAD, alert, oriented ×3, BMI 27 kg/m².  
- **Vital Signs:** BP 128/78 mmHg, HR 72 bpm, RR 16/min, SpO₂ 98% RA, Temp 36.8°C.  
- **HEENT:** Normocephalic, atraumatic, mucous membranes moist.  
- **Neck:** Supple, no cervical adenopathy.  
- **Cardiovascular:** Regular rate/rhythm, S₁S₂ normal, no murmurs.  
- **Respiratory:** Clear breath sounds bilaterally, no rales/wheezes, good air entry.  
- **Abdomen:** Soft, non‑distended, normoactive bowel sounds, no hepatosplenomegaly, no tenderness.  
- **Extremities:** No clubbing, cyanosis, edema. Peripheral pulses intact.  
- **Skin:** Warm, dry, no lesions.  
- **Neurological:** Grossly intact cranial nerves II‑XII, strength 5/5 UE/LE, sensation preserved, gait steady.  

---

### Laboratory Results *(drawn today)*

| Test | Result | Reference |
|------|--------|-----------|
| CBC w diff | WBC 6.2 (4‑10) k/µL, ANC 3.4 (1.5‑7.5), Hb 13.8 (g/dL), Plts 210 (k/µL) | Normal |
| Comprehensive Metabolic Panel | Na⁺ 138 (mEq/L), K⁺ 4.2, Cl⁻ 102, CO₂ 24, BUN 15, Cr 0.92, Glucose 118 mg/dL (random), AST 38 (U/L) ↑, ALT 42 (U/L) ↑, Alk Phos 84, Total Bilirubin 0.6 | Transaminases ≤2×ULN |
| Lipid panel | LDL 112 mg/dL, HDL 46 mg/dL, TG 140 mg/dL | — |
| Hemoglobin A1c | 7.2 % (target <7%) | Slightly above goal |
| Serum CEA | 2.1 ng/mL (≤5) | Within normal limits |
| Urinalysis | Neg for protein/glucose/blood | — |

*(Prior trend: transaminases plateaued at ≈40 U/L for >6 months; glycemic control improved after insulin titration.)*

---

### Imaging Results

**Chest CT (contrast‑enhanced)** – Performed 4 weeks ago, reviewed today.

- Right middle lobe: Subsolid nodule measuring **0.62 cm x 0.58 cm**, unchanged compared with prior study (0.61 cm). No solid component, margins smooth, no cavitation.
- Left lung fields: Post‑lobectomy changes without evidence of recurrence.
- Mediastinum/hilum: No enlarged lymph nodes; stations 5,6,7,10L surgically cleared previously remain negative.
- Osseous structures: No destructive lesions.

Interpretation: Radiographically stable disease per RECIST v1.1 criteria (non‑progressive, non‑regressive). No new pulmonary or extrapulmonary foci.

---

### Assessment

1. **KRAS‑mutant NSCLC – metastatic/recurrent disease, currently stable on sotorasib 960 mg QD**  
   - Ongoing durable disease control ≥5 yr; no radiographic progression.  
2. **Treatment‑related toxicities**  
   - *Grade 1 transaminitis*: Stable, asymptomatic.  
   - *Diarrhea*: Resolved; occasional mild episodes managed with OTC loperamide.  
   - *Hyperglycemia (insulin-dependent Type 2 DM secondary to KRAS inhibitor)* – Controlled on basal‑bolus regimen; A1c mildly elevated.  
3. **Fatigue** – Likely multifactorial (therapy, sleep hygiene); otherwise benign.  
4. **Performance Status** – ECOG 0, fully active.  

---

### Plan

| Item | Details |
|------|---------|
| **Continue sotorasib** | Maintain Lumakras® 960 mg PO daily. Reassess tolerance at next visit. Consider dose hold only if hepatic enzymes rise >3×ULN or symptomatic worsening. |
| **Laboratory Monitoring** | Repeat CBC/CMP including liver function tests in 6 weeks; repeat fasting glucose/HgbA1c in 3 months. |
| **Insulin Management** | Current regimen (Glargine 20 U HS, Lispro sliding scale) appears adequate. Encourage SMBG q·day, diet counseling, and annual ophthalmology screening. Adjust doses pending upcoming A1c. |
| **GI Symptom Control** | Keep loperamide 2 mg PRN up to 8 mg/day; advise hydration and fiber intake. |
| **Imaging Surveillance** | Schedule thin‑slice Chest CT in 12 weeks (±2 wk) per NCCN recommendation for KRAS‑directed therapy. Should there be any symptom suggestive of progression, obtain sooner. |
| **Supportive Care** | Discuss potential enrollment in a prospective registry for long‑term KRAS inhibitors. Offer referral to survivorship clinic for lifestyle optimization (exercise, nutrition). |
| **Vaccinations** | Ensure influenza vaccine annually; COVID‑19 booster updated; pneumococcal vaccination per CDC guidelines (PCV20 then PPSV23). |
| **Follow‑up Appointment** | Return in 3 months for office evaluation, sooner if new symptoms develop. |
| **Documentation** | Update problem list, medication reconciliation, and provide copy of latest imaging to patient portal. |

**Signature:** ___________________________  
Dr. ____________, MD – Medical Oncology  
[Institution Name]  

--- 

*Prepared electronically; dictation verified.*"