Make discharge summary format for medical oncology with USG abdomen, b

Make discharge summary format for medical oncology with USG abdomen, biopsy, ct scans, pet ct, and lab investigations, with discharge medication just document don't make pdf

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~/discharge-summary/Medical_Oncology_Discharge_Summary.md

# MEDICAL ONCOLOGY DISCHARGE SUMMARY

---

## HOSPITAL DETAILS
**Hospital Name:** ___________________________________________
**Department:** Medical Oncology
**Unit / Ward:** ___________________________________________

---

## PATIENT INFORMATION

| Field | Details |
|---|---|
| **Patient Name** | |
| **Age / Sex** | |
| **Date of Birth** | |
| **MRD / UHID No.** | |
| **IP No.** | |
| **Ward / Bed No.** | |
| **Date of Admission** | |
| **Date of Discharge** | |
| **Total Duration of Stay** | Days |
| **Consultant Oncologist** | Dr. |
| **Resident / Fellow** | Dr. |

---

## DIAGNOSIS

**Primary Diagnosis:**
___________________________________________

**Histological Type:**
___________________________________________

**Stage (TNM / Ann Arbor / Other):**
___________________________________________

**Secondary / Co-morbid Diagnoses:**
1.
2.
3.

---

## PRESENTING COMPLAINTS

| # | Complaint | Duration |
|---|---|---|
| 1 | | |
| 2 | | |
| 3 | | |
| 4 | | |

---

## HISTORY OF PRESENT ILLNESS

___________________________________________
___________________________________________
___________________________________________
___________________________________________

---

## PAST HISTORY

- **Previous Malignancy:** Yes / No — Details: ___________
- **Previous Surgery:** Yes / No — Details: ___________
- **Previous Chemotherapy:** Yes / No — Regimen / Cycles: ___________
- **Previous Radiation Therapy:** Yes / No — Site / Dose: ___________
- **Previous Immunotherapy / Targeted Therapy:** Yes / No — Details: ___________
- **Diabetes Mellitus:** Yes / No
- **Hypertension:** Yes / No
- **Cardiac Disease:** Yes / No
- **Other Comorbidities:** ___________

---

## PERSONAL HISTORY

- **Smoking:** Yes / No / Ex-smoker — Pack years: ___
- **Alcohol:** Yes / No
- **Tobacco Chewing:** Yes / No
- **Occupation:** ___________________________________________
- **Dietary Habits:** Vegetarian / Non-Vegetarian / Mixed
- **Allergies:** ___________________________________________

---

## FAMILY HISTORY

___________________________________________

---

## EXAMINATION ON ADMISSION

### General Examination
- **General Condition:** Fair / Moderate / Poor
- **Consciousness:** Alert / Drowsy / Obtunded
- **ECOG Performance Status:** 0 / 1 / 2 / 3 / 4
- **Height:** ___ cm | **Weight:** ___ kg | **BSA:** ___ m²
- **Pulse:** ___ bpm | **BP:** ___/___mmHg | **Temperature:** ___°F
- **SpO2:** ___% (Room Air / O2 support)
- **Pallor:** Yes / No | **Icterus:** Yes / No
- **Lymphadenopathy:** Yes / No — Site / Size: ___________
- **Oedema:** Yes / No — Site: ___________

### Systemic Examination
- **Respiratory System:** ___________________________________________
- **Cardiovascular System:** ___________________________________________
- **Abdomen:** ___________________________________________
- **Nervous System:** ___________________________________________
- **Local Examination / Primary Site:** ___________________________________________

---

## INVESTIGATIONS

---

### A. LABORATORY INVESTIGATIONS

#### Complete Blood Count (CBC)

| Parameter | Value | Reference Range | Date |
|---|---|---|---|
| Haemoglobin (g/dL) | | 12-16 | |
| Total WBC (cells/µL) | | 4000-11000 | |
| Neutrophils (%) | | 50-70 | |
| Lymphocytes (%) | | 20-40 | |
| Platelets (×10³/µL) | | 150-400 | |
| Haematocrit (%) | | 36-46 | |
| MCV (fL) | | 80-100 | |

#### Renal Function Tests (RFT)

| Parameter | Value | Reference Range | Date |
|---|---|---|---|
| Blood Urea (mg/dL) | | 10-40 | |
| Serum Creatinine (mg/dL) | | 0.6-1.2 | |
| eGFR (mL/min/1.73m²) | | >60 | |
| Serum Sodium (mEq/L) | | 135-145 | |
| Serum Potassium (mEq/L) | | 3.5-5.1 | |
| Serum Chloride (mEq/L) | | 98-107 | |

#### Liver Function Tests (LFT)

| Parameter | Value | Reference Range | Date |
|---|---|---|---|
| Total Bilirubin (mg/dL) | | 0.2-1.2 | |
| Direct Bilirubin (mg/dL) | | 0-0.4 | |
| AST / SGOT (U/L) | | 10-40 | |
| ALT / SGPT (U/L) | | 7-56 | |
| Alkaline Phosphatase (U/L) | | 44-147 | |
| Total Protein (g/dL) | | 6.0-8.3 | |
| Serum Albumin (g/dL) | | 3.5-5.0 | |

#### Coagulation Profile

| Parameter | Value | Reference Range | Date |
|---|---|---|---|
| PT (seconds) | | 11-13.5 | |
| INR | | 0.8-1.1 | |
| aPTT (seconds) | | 25-35 | |

#### Tumour Markers

| Marker | Value | Reference Range | Date |
|---|---|---|---|
| CEA (ng/mL) | | <5 | |
| CA 19-9 (U/mL) | | <37 | |
| CA 125 (U/mL) | | <35 | |
| AFP (ng/mL) | | <10 | |
| PSA (ng/mL) | | <4 | |
| Beta-HCG (mIU/mL) | | <5 | |
| LDH (U/L) | | 140-280 | |
| Others: | | | |

#### Thyroid Function / Other Endocrine

| Parameter | Value | Reference Range | Date |
|---|---|---|---|
| TSH (µIU/mL) | | 0.4-4.0 | |
| Free T4 (ng/dL) | | 0.8-1.8 | |
| Cortisol (µg/dL) | | 6-23 | |

#### Other Investigations

| Parameter | Value | Reference Range | Date |
|---|---|---|---|
| Blood Sugar Fasting (mg/dL) | | 70-100 | |
| HbA1c (%) | | <5.7 | |
| Uric Acid (mg/dL) | | 2.4-6.0 | |
| Calcium (mg/dL) | | 8.5-10.5 | |
| Phosphorus (mg/dL) | | 2.5-4.5 | |
| Magnesium (mg/dL) | | 1.5-2.5 | |
| CRP (mg/L) | | <10 | |
| Procalcitonin (ng/mL) | | <0.5 | |
| Blood Culture | | Sterile | |
| Urine Culture | | Sterile | |
| Hepatitis B (HBsAg) | | Non-reactive | |
| Anti-HCV | | Non-reactive | |
| HIV I & II | | Non-reactive | |

---

### B. ULTRASONOGRAPHY (USG) ABDOMEN

**Date of USG:** ___________________________________________

**Referring Indication:** ___________________________________________

**Findings:**

| Structure | Findings |
|---|---|
| Liver | |
| Gall Bladder | |
| Common Bile Duct | |
| Spleen | |
| Pancreas | |
| Kidneys (Right / Left) | |
| Urinary Bladder | |
| Uterus / Ovaries (if applicable) | |
| Lymph Nodes (para-aortic / iliac / mesenteric) | |
| Ascites | |
| Any Mass / SOL | |
| Other Findings | |

**USG Impression:**
___________________________________________
___________________________________________

**Reported by:** Dr. ___________________ | **Centre:** ___________________

---

### C. CT SCAN

#### CT Scan - 1

**Type:** CT Chest / CT Abdomen / CT Pelvis / CT Chest-Abdomen-Pelvis (CAP) / CT Brain / CT Neck / Other: ___

**Date:** ___________________ | **With / Without Contrast:** ___________________

**Indication:** ___________________________________________

**Key Findings:**

| Region / Structure | Findings |
|---|---|
| Primary Site / Tumour | |
| Lymph Nodes | |
| Liver | |
| Lungs | |
| Bones | |
| Adrenals | |
| Other Organs | |
| Pleural / Pericardial Effusion | |
| Ascites | |

**CT Impression:**
___________________________________________
___________________________________________

**Reported by:** Dr. ___________________ | **Centre:** ___________________

---

#### CT Scan - 2 (if applicable)

**Type:** ___________________ | **Date:** ___________________ | **Contrast:** ___

**Findings / Impression:**
___________________________________________
___________________________________________

**Reported by:** Dr. ___________________ | **Centre:** ___________________

---

### D. PET-CT SCAN

**Date of PET-CT:** ___________________________________________

**Tracer Used:** FDG (18F-Fluorodeoxyglucose) / Other: ___________

**Indication:** Staging / Restaging / Response Assessment / Recurrence Evaluation

**Findings:**

| Site | FDG Avidity (Yes/No) | SUVmax | Size (cm) | Remarks |
|---|---|---|---|---|
| Primary Tumour | | | | |
| Regional Lymph Nodes | | | | |
| Mediastinal Nodes | | | | |
| Para-aortic / Iliac Nodes | | | | |
| Liver | | | | |
| Lungs | | | | |
| Bones (specify sites) | | | | |
| Adrenals | | | | |
| Brain | | | | |
| Peritoneum | | | | |
| Other Sites | | | | |

**Overall Metabolic Stage:**
___________________________________________

**PET-CT Impression:**
___________________________________________
___________________________________________

**Reported by:** Dr. ___________________ | **Centre:** ___________________

---

### E. BIOPSY / HISTOPATHOLOGY

#### Biopsy - 1

**Date of Biopsy:** ___________________ | **HP No. / Lab Ref:** ___________________

**Site of Biopsy:** ___________________________________________

**Type of Biopsy:** FNAC / Core Needle Biopsy / Incisional / Excisional / Bone Marrow / Endoscopic / Other: ___

**Gross Description:**
___________________________________________

**Microscopic Description:**
___________________________________________

**Histological Diagnosis:**
___________________________________________

**Grade (if applicable):** Well / Moderately / Poorly Differentiated | Grade: ___

**Lymphovascular Invasion (LVI):** Yes / No / Indeterminate

**Perineural Invasion (PNI):** Yes / No / Indeterminate

**Margins (if surgical specimen):** Clear / Involved — Distance: ___ mm

**Immunohistochemistry (IHC):**

| Marker | Result | Interpretation |
|---|---|---|
| ER | | |
| PR | | |
| HER2 | | |
| Ki-67 (%) | | |
| PD-L1 (TPS / CPS) | | |
| ALK | | |
| ROS1 | | |
| EGFR | | |
| CD20 | | |
| CD3 | | |
| Others | | |

**Molecular / Genomic Testing (NGS / FISH / PCR):**

| Test | Result | Date |
|---|---|---|
| EGFR Mutation | | |
| KRAS Mutation | | |
| BRAF Mutation | | |
| ALK FISH | | |
| BRCA 1/2 | | |
| MSI / MMR Status | | |
| TMB | | |
| Others | | |

**Reported by:** Dr. ___________________ | **Centre:** ___________________

---

#### Biopsy - 2 (if applicable)

**Date:** ___________________ | **Site:** ___________________ | **HP No.:** ___________________

**Findings / Diagnosis:**
___________________________________________
___________________________________________

**Reported by:** Dr. ___________________ | **Centre:** ___________________

---

## TREATMENT GIVEN DURING ADMISSION

### Chemotherapy / Systemic Therapy

**Regimen Name:** ___________________________________________

**Cycle No.:** ___ of ___ | **Day:** ___

| Drug | Dose | Route | Frequency | Days |
|---|---|---|---|---|
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |

**Pre-medications Given:**
- Antiemetics: ___________________________________________
- Steroids: ___________________________________________
- Hydration: ___________________________________________
- G-CSF: ___________________________________________
- Others: ___________________________________________

**Targeted Therapy / Immunotherapy (if applicable):**

| Drug | Dose | Route | Frequency |
|---|---|---|---|
| | | | |
| | | | |

**Radiation Therapy (if given during admission):**
- Site: ___________________________________________
- Dose / Fractions delivered this admission: ___________________________________________

---

## CLINICAL COURSE DURING ADMISSION

___________________________________________
___________________________________________
___________________________________________
___________________________________________

**Complications / Adverse Events:**
- ___________________________________________
- ___________________________________________

**Response to Treatment:**
Complete Response / Partial Response / Stable Disease / Progressive Disease / Not Evaluable

---

## CONDITION AT DISCHARGE

- **General Condition:** Stable / Improving / Guarded
- **ECOG PS at Discharge:** ___
- **Vitals at Discharge:** Pulse: ___ BP: ___/___ SpO2: ___%
- **Weight at Discharge:** ___ kg

---

## DISCHARGE MEDICATIONS

> **Note to Pharmacist / Patient:** Please dispense exactly as listed. Do not substitute without oncologist approval.

| # | Drug Name | Dose | Route | Frequency | Duration | Special Instructions |
|---|---|---|---|---|---|---|
| 1 | | | | | | |
| 2 | | | | | | |
| 3 | | | | | | |
| 4 | | | | | | |
| 5 | | | | | | |
| 6 | | | | | | |
| 7 | | | | | | |
| 8 | | | | | | |
| 9 | | | | | | |
| 10 | | | | | | |

**Supportive Medications:**

| # | Drug | Dose | Frequency | Duration | Purpose |
|---|---|---|---|---|---|
| 1 | | | | | Antiemetic |
| 2 | | | | | Antacid / PPI |
| 3 | | | | | Haematinic |
| 4 | | | | | G-CSF / Growth Factor |
| 5 | | | | | Analgesic |
| 6 | | | | | Other |

**Medications to STOP / HOLD:**
- ___________________________________________

**Medications Requiring Monitoring:**
- ___________________________________________

---

## DIETARY / LIFESTYLE ADVICE

- ___________________________________________
- ___________________________________________
- ___________________________________________

---

## FOLLOW-UP PLAN

**Next Appointment:** _____________________________ (Date)

**Clinic / OPD:** Medical Oncology OPD

**Plan at Next Visit:**
- Labs to be done before visit: ___________________________________________
- Imaging required: ___________________________________________
- Next cycle of chemotherapy: Cycle ___ on ___________________________________________
- Other: ___________________________________________

**Emergency Contact:** ___________________________________________

---

## INSTRUCTIONS TO PATIENT / ATTENDANT

1. Report immediately to the emergency department if fever >38°C (100.4°F), chills, severe vomiting, bleeding, breathlessness, or chest pain.
2. Maintain strict hand hygiene and avoid crowded places during neutropenia period.
3. Do not miss any scheduled medication dose.
4. Bring all reports and this summary at every visit.
5. ___________________________________________
6. ___________________________________________

---

## TREATING TEAM

| Role | Name | Signature |
|---|---|---|
| Consultant Oncologist | Dr. | |
| Senior Resident | Dr. | |
| Registrar / Intern | Dr. | |
| Nursing In-charge | | |

**Date of Discharge Summary:** ___________________________________________

---

*This discharge summary has been prepared based on available clinical information and investigations at the time of discharge. All reports are attached herewith. For queries, contact the Medical Oncology Department.*

---

The discharge summary document has been created and saved here:

Medical Oncology Discharge Summary

MD File · MD

Here is a breakdown of everything included in the template:

Patient & Admission Details

Full patient demographics, MRD/UHID, IP number, admission/discharge dates, duration of stay, and treating team.

Diagnosis Section

Primary diagnosis, histological type, TNM/Ann Arbor staging, and co-morbidities.

Investigations - 5 dedicated sections:

Laboratory Investigations - CBC, RFT, LFT, coagulation, tumour markers (CEA, CA19-9, CA125, AFP, PSA, Beta-HCG, LDH), thyroid function, blood/urine cultures, viral serology (HBsAg, HCV, HIV), and general metabolic panels - all with reference ranges and date columns.
USG Abdomen - Structured table covering liver, gallbladder, CBD, spleen, pancreas, kidneys, bladder, uterus/ovaries, lymph nodes, ascites, and any mass/SOL, with impression and reporting doctor fields.
CT Scans - Two separate CT scan blocks (for baseline + restaging or multi-site scanning), each with a findings table by region (primary site, nodes, liver, lungs, bones, adrenals, effusions), impression, date, contrast details.
PET-CT Scan - Tabular format with site, FDG avidity (Yes/No), SUVmax, lesion size, and remarks for each site; tracer type; indication (staging/restaging/response); overall metabolic stage; impression.
Biopsy / Histopathology - Two biopsy blocks with gross and microscopic description, histological diagnosis, grade, LVI/PNI, margins, a full IHC table (ER, PR, HER2, Ki-67, PD-L1, ALK, ROS1, EGFR, CD markers), and molecular/genomic testing (EGFR, KRAS, BRAF, BRCA, MSI/MMR, TMB, NGS/FISH).

Treatment During Admission

Chemo regimen, cycle number, drug/dose/route/day table, pre-medications, targeted therapy/immunotherapy block, and radiation details.

Discharge Medications

A 10-row main medication table (drug, dose, route, frequency, duration, special instructions).
A separate supportive medications table (antiemetics, PPI, haematinics, G-CSF, analgesics).
Dedicated rows for medications to STOP/HOLD and those requiring monitoring.

Follow-up & Patient Instructions

Next appointment date, pre-visit labs and imaging, next cycle planning, emergency red flag symptoms, and general oncology safety instructions.

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