Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Reason for Visit:
Initial evaluation for suspected pancreatic cancer
Follow-up for diagnosed pancreatic cancer (monitoring response to
treatment, surveillance)
Evaluation of new or worsening symptoms
Chief Complaint:
May vary depending on stage and location of the tumor:
Abdominal pain (upper left quadrant)
Back pain (radiating to the back)
Unexplained weight loss
Jaundice (yellowing of the skin and eyes)
Nausea and vomiting
Loss of appetite
New onset diabetes or worsening of existing diabetes
History of Present Illness:
Onset, duration, and severity of symptoms.
Risk factors for pancreatic cancer (e.g., smoking, family history
of pancreatic cancer, chronic pancreatitis).
Previous medical history of diabetes or other pancreatic diseases.
Past Medical History:
Underlying medical conditions.
Previous surgeries (relevant surgeries on the abdomen or pancreas).
Family History:
Family history of pancreatic cancer (increases risk).
Social History:
Smoking history (significant risk factor).
Alcohol use (may increase risk).
Physical Examination:
General examination: Assess for signs of malnutrition (weight loss,
muscle wasting), jaundice, and ascites (fluid collection in the abdomen).
Abdominal examination: Palpate for abdominal masses or tenderness.
Diagnostic Tests (if indicated):
Imaging studies:
CT scan with contrast: First-line imaging for suspected pancreatic
cancer.
MRI scan: May provide additional information about tumor
involvement of nearby blood vessels.
Endoscopic ultrasound (EUS): May be used to visualize the pancreas
in more detail and obtain tissue samples for biopsy.
Laboratory tests:
Tumor markers (CA 19-9): Elevated levels may suggest pancreatic
cancer, but not diagnostic on its own.
Liver function tests: May be abnormal in presence of jaundice.
Assessment:
Suspected pancreatic cancer: Based on clinical presentation
(symptoms and physical examination findings) and supported by imaging studies.
Diagnosed pancreatic cancer: Confirmed by biopsy and pathological
examination. Stage of the cancer (extent of local and distant spread)
should be determined using the TNM staging system.
Presence of risk factors: Identify any factors that may have
contributed to the development of pancreatic cancer.
Differential Diagnoses:
Consider other conditions that may mimic pancreatic cancer:
Chronic pancreatitis
Peptic ulcer disease
Cholecystitis (gallbladder inflammation)
Liver cancer
Plan:
Treatment plan: Depends on the stage and type of pancreatic cancer,
patient’s overall health, and preferences. Treatment options may
include:
Surgery (Whipple procedure, pancreatectomy): Aims to remove the
tumor and surrounding tissues. May not be feasible in all stages.
Chemotherapy: May be used before or after surgery, depending on
the stage.
Radiation therapy: May be used in combination with chemotherapy.
Palliative care: Focuses on managing symptoms and improving quality
of life for patients with advanced-stage disease.
Multidisciplinary approach: Treatment typically involves
collaboration between oncologists, surgeons, gastroenterologists, and
other specialists depending on the specific needs of the patient.
Clinical trials: Patients may be eligible for clinical trials
investigating new treatment approaches.
Supportive care: Manage pain, nausea, vomiting, and other symptoms
associated with the cancer or its treatment.
Prognosis:
Prognosis depends on the stage of pancreatic cancer at diagnosis and
response to treatment. Early detection and treatment improve the
prognosis.
Patient Education:
Educate the patient about pancreatic cancer, risk factors, symptoms,
diagnosis, treatment options, and potential side effects.
Discuss the importance of follow-up care and monitoring for recurrence.
Provide resources for support groups and educational materials.