Date:
Patient:
MRN:
Attending Physician:
Reason for Visit:
Follow-up for esophageal cancer diagnosis
Evaluation of treatment response
Management of treatment side effects
New symptoms
History of Present Illness:
Briefly summarize the patient’s esophageal cancer diagnosis, including:
Date of diagnosis
Presenting symptoms (dysphagia, odynophagia, weight loss, etc.)
Esophageal cancer type (adenocarcinoma, squamous cell carcinoma, etc.)
Tumor stage (TNM classification)
Past Medical History:
Include any relevant past medical conditions, such as GERD, Barrett’s esophagus, smoking history, etc.
Social History:
Tobacco use (current and past)
Alcohol use
Diet
Family History:
History of esophageal cancer or other GI malignancies in first-degree relatives
Medications:
List all current medications, including chemotherapy, radiation therapy, pain medications, and supportive medications.
Physical Exam:
General: Weight, appearance of distress
Vital Signs: Temperature, pulse, blood pressure, oxygen saturation
HEENT: Oral cavity exam for thrush or mucositis
Neck: Lymph node palpation
Chest: Respiratory examination for signs of effusion
Abdomen: Palpation for hepatomegaly or ascites
Labs:
List any recent laboratory tests, including CBC, electrolytes, liver function tests, and tumor markers (if applicable).
Imaging:
Mention any recent imaging studies, such as chest X-ray, CT scan, PET scan, or endoscopy with biopsy results.
Assessment:
Summarize the patient’s current clinical status:
Stage of esophageal cancer
Response to treatment (if applicable)
Presence of any complications
Plan:
Outline the next steps in the patient’s care:
Treatment plan (surgery, chemotherapy, radiation therapy, or combination)
Follow-up schedule for imaging, labs, and clinic visits
Management of treatment side effects and supportive care needs
Discuss any potential need for palliative care or hospice services
Prognosis:
Briefly discuss the patient’s prognosis based on the stage of the cancer and response to treatment.
Notes:
Include any additional relevant information not covered above.
Disclaimer: This is a template and should be adapted to the specific needs of each patient.