Date:
Patient:
MRN:
Clinician: (Gastroenterologist, Geneticist)
Reason for Visit:
Follow-up for FAP
Colonoscopy results and surveillance plan
Upper GI endoscopy results (if applicable)
Discussion of risk-reducing surgery options
Genetic counseling update
History of Present Illness:
Briefly describe the patient’s current status:
Age at diagnosis of FAP (genetic testing or family history)
Presence of any gastrointestinal (GI) symptoms (abdominal pain, rectal bleeding)
FH (family history) of FAP or colorectal cancer (CRC) in first-degree relatives
Past Medical History:
Include any relevant past medical conditions, such as:
Previous abdominal surgeries (including polypectomies)
History of upper gastrointestinal (GI) polyps
Family History:
Document details of FAP or CRC in first-degree relatives (age of onset, type of surgery).
Social History:
Smoking history (current and past) – risk factor for CRC
Labs:
Consider mentioning recent labs as relevant, such as:
CBC (complete blood count) – may be checked pre-operatively
Electrolytes – important for surgery preparation
Imaging:
Colonoscopy:
Frequency of colonoscopies depends on age, polyp burden, and family history.
Mention results of recent colonoscopy, including number, size, and location of polyps.
Upper GI endoscopy (if applicable):
Consider mentioning findings if performed to evaluate for upper GI polyps (less common in FAP).
Pathology:
Briefly describe pathology results of any polyps removed during endoscopies (adenomatous vs. hyperplastic).
Genetics:
Document the specific FAP mutation identified (if known).
Mention any recent genetic counseling updates or discussions about testing cascade for family members.
Assessment:
Confirm the diagnosis of FAP based on genetic testing or family history.
Assess the patient’s current disease status based on colonoscopy findings and risk factors for CRC.
Discuss the risk of desmoid tumors (non-cancerous tumors) in FAP patients.
Plan:
Outline the management plan based on the patient’s age, polyp burden, and family history:
Colonoscopy surveillance: Regular colonoscopies with polypectomy to remove polyps before they become cancerous. The frequency of colonoscopies is individualized.
Chemoprevention: Consider medications like sulindac or aspirin to reduce polyp recurrence (discuss potential risks and benefits with the patient).
Risk-reducing surgery: Discuss the options and timing of prophylactic colectomy (removal of the colon) to prevent CRC.
Options include total colectomy with ileorectal anastomosis (preserving the rectum) or proctocolectomy with ileostomy (creating an external opening for stool).
Upper GI endoscopy: May be recommended at specific intervals for some FAP patients to check for upper GI polyps.
Prognosis:
Briefly discuss the prognosis. With regular surveillance and risk-reducing strategies, FAP patients can significantly reduce their risk of developing CRC.
Education:
Document any education provided to the patient regarding:
The nature of FAP and its implications
Importance of regular colonoscopy surveillance
Benefits and risks of risk-reducing surgery options
Diet and lifestyle modifications that may reduce CRC risk
Support groups and resources available for FAP patients
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the plan and any emotional concerns they may have.
Consider mentioning the importance of lifelong follow-up and potential need to adjust management over time.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a healthcare professional for diagnosis and treatment recommendations.