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Medical History

  What is in my medical record?
  What information is obtained from my history and physical exam?
  What information do my providers expect to get from my x-rays?
  What information will my providers get from my laboratory studies?

What is in my medical record?
Your health care providers will keep a medical record, often called a chart, which is a composite of the physician's consultation and progress notes which document each visit. The chart reflects the care required for a person with cancer and includes notes from nurses, social workers, nutritionists, health educators, and other providers involved in your care. This chart also contains laboratory, radiology, pathology, and other reports. Correspondence to and from your physicians and other documents are also kept in your medical record. Some patients find it helpful to review their own charts. If questions arise in this review, it is extremely important that these be discussed with your health care professional.

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What information is obtained from my history and physical exam?
By taking a history, your health care providers can obtain information about your symptoms. The types of questions that you most likely will be asked about your symptoms will be the duration, change over a period of time, or things that make the symptom get better or worse. For example, if you have pain(s), where is it, what is the severity, and what can be done to relieve the pain. By doing a systematic review of associated signs and symptoms your providers can uncover clinical indications of organ or functional problems which may be related to your cancer or unrelated medical conditions.

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What information do my providers expect to get from my x-rays?
X-rays and scans are used to image the body in order to look for evidence of tumor(s). Usually tumor images appear differently than normal organ images. For example, in the lungs, cancer can be distinguished from normal lung tissue. CT scans provide three-dimensional composite x-ray images. MRI scans provide a three-dimensional composite of images based on different physical properties of cancer compared to normal tissue. Nuclear medicine scans are sometimes used to image the bones for evidence of tumor replacing normal bone called bone metastases.

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What information will my providers get from my laboratory studies?
A blood sample is usually sent to the laboratory for analysis of the three main cellular elements (red blood cells, white blood cells, and platelets), and a chemical analysis of organ function including the liver and kidneys. Additional testing may be done looking for "tumor markers," proteins that can be found in the blood which are abnormally produced by certain cancers. Samples of other body fluids may also be sent to the laboratory for analysis.

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