Date:
Patient:
MRN:
Clinician: (Hepatobiliary Surgeon, Oncologist)
Reason for Visit:
Follow-up for gallbladder cancer
Evaluation of symptoms and response to treatment (if applicable)
Review of imaging results
Treatment plan discussion
History of Present Illness:
Briefly describe the patient’s current status:
Time since diagnosis of gallbladder cancer
Presence and severity of any symptoms (abdominal pain, nausea, vomiting, jaundice, weight loss)
Current treatment regimen (surgery, chemotherapy, radiation therapy) and response to therapy
Past Medical History:
Previous surgeries (cholecystectomy – gallbladder removal) – may be a risk factor
Gallstones (may be a risk factor)
Other medical conditions (important for treatment considerations)
Family History:
Family history of cancer (not a strong risk factor for gallbladder cancer)
Social History:
Not typically relevant for gallbladder cancer, but may include smoking history (potential risk factor)
Physical Exam:
Vital Signs: May be normal or abnormal depending on the stage of cancer and presence of complications.
Abdominal: Palpation for right upper quadrant tenderness or mass.
Jaundice: Examination of the skin and sclerae for yellowing.
Labs:
Liver function tests (LFTs): Elevated bilirubin, alkaline phosphatase, and liver enzymes may suggest gallbladder cancer or complications (bile duct obstruction).
Tumor markers (CA 19-9): Elevated levels may be suggestive of gallbladder cancer, but not specific for diagnosis.
Consider mentioning other labs ordered as needed:
Complete Blood Count (CBC) – to assess for anemia or signs of infection.
Imaging:
Previous imaging studies: Briefly describe the findings of imaging studies used for diagnosis (abdominal ultrasound, CT scan, MRI scan) at the time of diagnosis.
Current imaging studies: Describe the findings of any recent imaging studies used to monitor disease progression or assess response to treatment (CT scan, MRI scan, PET scan).
Assessment:
Summarize the current disease status based on symptoms, physical exam, labs, and imaging:
Stage of gallbladder cancer (based on tumor size, lymph node involvement, and distant metastasis).
Treatment received and response to therapy (tumor shrinkage, improvement in symptoms).
Consideration of recurrence if applicable.
Plan:
Outline the treatment plan based on the assessment:
Surgery: Cholecystectomy with possible lymph node dissection depending on the stage. In advanced cases, more extensive surgery may be necessary.
Chemotherapy: Adjuvant chemotherapy after surgery to reduce the risk of recurrence.
Radiation therapy: May be used in combination with surgery or for palliative purposes (pain management in advanced stages).
Clinical trial participation: Discuss potential benefits and risks of participation.
Palliative care: Focus on symptom management and improving quality of life in advanced stages.
Prognosis:
Briefly discuss the prognosis. The prognosis for gallbladder cancer depends on the stage at diagnosis and response to treatment. Early-stage cancers have a better prognosis than advanced stages.
Emphasize the importance of regular follow-up to monitor for recurrence.
Education:
Document any education provided to the patient regarding:
The nature of gallbladder cancer, its stages, and treatment options
The potential side effects of treatment and how to manage them
The importance of regular follow-up and monitoring for recurrence
The emotional impact of a cancer diagnosis and available support resources
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about their condition.
Consider mentioning the importance of maintaining a healthy lifestyle (diet, exercise) as tolerated during treatment.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a hepatobiliary surgeon or oncologist for diagnosis, treatment recommendations, and prognosis.