Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Reason for Visit:
Initial evaluation for suspected ovarian cancer
Follow-up for diagnosed ovarian cancer (monitoring response to
treatment, surveillance)
Evaluation of symptoms or treatment side effects
Chief Complaint:
(Symptoms can vary depending on stage)
Pelvic pain or pressure
Abdominal bloating or swelling
Difficulty eating or feeling full quickly
Urinary urgency or frequency
Abnormal vaginal bleeding or discharge
Fatigue
Back pain
History of Present Illness:
Onset, duration, and severity of symptoms.
Progression of symptoms over time.
Presence of any risk factors (e.g., family history, BRCA gene mutations,
endometriosis, obesity, nulliparity).
Previous history of pelvic surgeries or treatments.
Past Medical History:
Underlying medical conditions.
Previous surgeries (relevant surgeries on the ovaries or pelvis).
Family History:
Family history of ovarian cancer, breast cancer, or other cancers.
Family history of BRCA gene mutations.
Social History:
History of tobacco use.
Physical Examination:
Pelvic examination: Palpate for ovarian masses or ascites (fluid
accumulation in the abdomen).
Abdominal examination: Assess for distention, masses, or tenderness.
Diagnostic Tests (if indicated):
Pelvic ultrasound: Initial imaging test to visualize the ovaries and
uterus for suspicious masses or fluid collections.
CA-125 blood test: Tumor marker that can be elevated in ovarian cancer
but is not diagnostic on its own.
CT scan or MRI scan: May be used to further evaluate suspicious findings
on ultrasound and assess for spread of cancer.
Biopsy:** Tissue sample from the suspicious mass is essential for
definitive diagnosis. Biopsy can be obtained through various techniques
(e.g.,
fine-needle aspiration, laparoscopy).
Assessment:
Suspected ovarian cancer: Based on clinical presentation (symptoms
and physical examination findings) and supported by imaging studies
(if performed).
Diagnosed ovarian cancer: Confirmed by biopsy and pathological
examination. Stage of the cancer (extent of local and distant spread)
should be determined using the FIGO staging system.
Presence of risk factors: Identify any factors that may have
contributed to the development of ovarian cancer.
Differential Diagnoses:
Consider other conditions that may mimic ovarian cancer:
Uterine fibroids
Pelvic inflammatory disease (PID)
Endometriosis
Irritable bowel syndrome (IBS)
Plan:
Treatment plan: Depends on the stage and type of ovarian cancer,
patient’s overall health, and preferences. Treatment options may
include:
Surgery: Debulking surgery (remove as much of the cancer as
possible)
is the mainstay of treatment for most ovarian cancers.
Chemotherapy: May be used before or after surgery, depending on
the stage of the cancer.
Targeted therapy: Newer medications that target specific molecular
abnormalities found in some ovarian cancers.
Multidisciplinary approach: Treatment typically involves
collaboration between oncologists, surgeons, gynecologists, and other
specialists depending on the specific needs of the patient.
Supportive care: Manage side effects of treatment and improve
quality of life. May include pain management, nutritional counseling, and
psychological support.
Surveillance: Regular follow-up appointments with monitoring for
recurrence after treatment completion.
Prognosis:
Prognosis depends on the stage of ovarian cancer at diagnosis and
response to treatment. Early detection and treatment improve the
prognosis.
Patient Education:
Educate the patient about ovarian cancer, risk factors, symptoms,
diagnosis, treatment options, and potential side effects.
Discuss the importance of follow-up care and monitoring for recurrence.