Former smoker — 40 pack-years, quit at diagnosis 12/2025. Retired machinist; lives with wife. Rare alcohol. Family history non-contributory.
Review of SystemsHide
**Pain**Hide
+ New Grade Scale value
Treatment Recommendations for Pain
**Depression**Hide
+ New Grade Scale value
Physical ExamHide
Lab/Test ResultsHide
07/14/2026 — TSH 8.9 µIU/mL (H) · Free T4 0.9 ng/dL · CBC and CMP within normal limits
06/29/2026 — CT chest w/ contrast: treated RUL primary further decreased; no new nodules; no pneumonitis pattern
ACPHide
Info in Assessment will be in the pt's CCDA - "Care Plan/Assmt" area
Advance care planning discussed at consult; healthcare proxy on file.
Tx Hx/SummaryHide
Summary maintained by attending physician (see consolidation planning note, 2/26/2026).
AssessmentHide
Info in Assessment will be in the pt's CCDA - "Care Plan/Assmt" area
Medical Decision MakingHide
Diagnosis 1
Diagnosis
Stable at goal Stable but not at goal Unstable Progressive disease Rapid deterioration
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DiscussionHide
Diagnosis, treatment options, and prognosis discussed