Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Shortness of breath / Chest pain / Pleural effusion (fluid around the lung) / Cough (may be dry or productive) / Fatigue / Night sweats / Weight loss / (Specify any other concerning symptoms)
History of Present Illness:
Onset, duration, and severity of symptoms.
Progression of symptoms over time.
Impact of symptoms on daily activities.
Previous history of asbestos exposure (occupational or environmental).
Past Medical History:
Smoking history (smoking can worsen symptoms and prognosis).
Previous diagnoses of lung diseases (e.g., COPD, asthma).
History of chest surgeries (e.g., prior pleural effusion drainage).
Medications:
List all current medications, including any pain medications or diuretics for pleural effusion.
Social History:
Current and past occupations with potential asbestos exposure (e.g., construction, shipyard work, insulation work).
Home environment and potential for secondary asbestos exposure (e.g., living with someone who worked with asbestos).
Family History:
Inquire about a family history of lung cancer or other asbestos-related diseases.
Physical Exam:
Vital signs: Assess for fever (may indicate infection), tachypnea (rapid breathing), and hypoxemia (low blood oxygen).
General observation: Look for signs of respiratory distress (use of accessory muscles, pursed-lip breathing).
Chest exam:
Decreased breath sounds on the affected side due to pleural effusion.
Tactile fremitus (feeling vibrations) may be diminished on the affected side.
Dullness to percussion (tapping) over the area of pleural effusion.
Cardiovascular exam: Assess for signs of cor pulmonale (right-sided heart failure) due to chronic lung disease.
Diagnostic Tests:
Chest X-ray: May show pleural effusion and may suggest underlying lung abnormalities.
CT scan of the chest: Provides detailed images of the chest wall, pleural space, and lungs. Can help identify the location and extent of the tumor.
Pleural fluid analysis: Fluid withdrawn from the pleural space is examined for mesothelioma cells, infectious agents, and other abnormalities.
Biopsy: Tissue sample obtained through pleural biopsy (needle aspiration) or video-assisted thoracic surgery (VATS) is examined under a microscope to confirm the diagnosis of mesothelioma.
Assessment:
Malignant pleural mesothelioma: State whether mesothelioma is confirmed, suspected, or ruled out based on clinical presentation, imaging findings, and pleural fluid analysis results (if available).
Mesothelioma cell type (if diagnosed): Specify the cell type of mesothelioma (epithelial, sarcomatoid, or biphasic).
Stage of disease (if diagnosed): If mesothelioma is confirmed, stage the disease based on imaging studies to determine the extent of spread.
Performance status: Assess the patient’s overall functional status using a scoring system (e.g., ECOG performance status).
Plan:
Definitive diagnosis (if not already confirmed): Discuss the need for a pleural biopsy to confirm the diagnosis of mesothelioma if not already done.
Multidisciplinary consultation: Recommend a multidisciplinary team approach to care, involving a pulmonologist, thoracic surgeon, medical oncologist, and palliative care specialist.
Treatment options (based on diagnosis, stage, and performance status):
Surgery: May be considered for some patients with early-stage disease.
Chemotherapy: The mainstay of treatment for most patients.
Radiation therapy: May be used alone or in combination with chemotherapy.
Pleural effusion management: Management of recurrent pleural effusions may involve thoracentesis (removal of fluid) or pleurodesis (procedure to prevent fluid buildup).
Clinical trials: Patients may be eligible for participation in clinical trials investigating new treatment approaches.
Pain management: A crucial aspect of care throughout the disease course. Medications and interventional techniques may be used to manage pain.