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Patient Medical Report

Complete patient history, investigations, treatment and specialist opinions
Generated: 2026-09-25 06:03 Patient Record: 3
Full Name
منى يوسف خلف
Identification Number
9522012113
Age
74
Gender
Female
Telephone Number
079971938
Record Created
2026-07-27 08:30
Last Updated
2026-07-27 08:51

History of Present Illness (HPI)

74Y FEMALE HTN, PRE-DIABETIC C/O Epigastric pain, Abdominal distention No weight loss, no bleeding per rectum.

Medical Conditions

2 record(s)
Condition Type Diagnosis Date ICD-10 Severity Status Notes
Dm Chronic - - - Active -
Hypertension Chronic - - - Active -

Family Medical History

0 record(s)
No family medical history was recorded.

Social History

No social history was recorded.

Surgeries

0 record(s)
No surgery records were recorded.

Chemotherapy

1 record(s)
Folfox
2026-04-23 - 2026-07-18
Treatment Plan
4 cycles of FOLFOX GIVEN C1 23/4/2026 C2 11/5/2026 C3 4/6/2026 LAST DOSE - 18/6/2026

Radiology Records

3 record(s)
Endoscopy - Upper Endoscopy
2026-07-13
Status
Completed
Attached Files
0
Facility
-
Radiologist
-
Clinical Indication
-
Findings
-
Impression
Large ugly looking lesion in incisura, multiple Bx taken.
Notes
-
CT Scan - CHEST ABD PELVIS
2026-07-05
Status
Completed
Attached Files
0
Facility
-
Radiologist
-
Clinical Indication
-
Findings
-
Impression
Previously noted circumferential wall thickening in the distal descending colon is significantly improved. Oedematous circumferential wall thickening is noted in the stomach with no significant changes regarding the previously noted lymph nodes.
Notes
-
Endoscopy - Colonoscopy
2026-04-07
Status
Completed
Attached Files
0
Facility
-
Radiologist
-
Clinical Indication
-
Findings
The scope was entered up to 50cm from AV, there is ugly looking circumferential wall thickening causing narrowing of the lumen, the scope could not be bypassed. Biopsies not taken because the pt already have the biopsies showing - invasive moderately differentiated colonic adenocarcinoma
Impression
-
Notes
-

Specialist Opinions

1 record(s)
Medical Oncology
2026-08-03
Specialist Name
-
Opinion Note
Lt hemicolectomy and total/subtotal gastrectomy
Recommendation
-

Laboratory Tests

4 record(s)
Date Test Category Result Reference Range Status Notes
2026-04-12 Hepatitis Profile Other Negative - Normal -
2026-03-16 CA19-9 Tumor Markers 3.79 U/ml 0-39 Normal -
2026-03-16 CA125 Tumor Markers 7.59 U/ml 0-35 Normal -
2026-03-16 CEA Tumor Markers 9.28 Ng/ml Up to 3 (non smoker), up to 5 (smoker) High -