Date: [Date of encounter]
Patient: [Patient Name]
Chief Complaint:
Document the patient’s main concern related to testicular cancer, such as a painless lump in the testicle, testicular pain, scrotal swelling, or any other relevant symptoms.
History of Present Illness:
Onset and duration of symptoms.
Characteristics of the testicular lump (size, consistency, unilateral/bilateral).
Presence of other symptoms (e.g., lower back pain, gynecomastia, cough, shortness of breath).
History of testicular trauma or infection.
Family history of testicular cancer.
Past Medical History:
Underlying medical conditions (e.g., undescended testes, Klinefelter syndrome).
Past surgeries (inguinal hernia repair, orchiectomy on the opposite side).
Medications:
List of current medications.
Social History:
Tobacco use (smoking may increase risk of testicular cancer).
Physical Exam:
Vital signs (elevated temperature may indicate infection).
General examination (assess for signs of weight loss, gynecomastia, lymphadenopathy).
Genitourinary examination:
Palpation of testicles (size, consistency, presence of lumps).
Evaluation of epididymis and vas deferens.
Inguinal lymph node examination.
Diagnostic Tests (as indicated):
Ultrasound: Initial imaging test to assess testicular mass and differentiate between solid tumor and fluid-filled cyst.
Tumor markers: Blood tests for alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (hCG) to aid in diagnosis and monitor response to treatment.
Orchiectomy: Surgical removal of the affected testicle, often performed diagnostically and therapeutically.
Pathological examination of the removed testicle confirms the diagnosis and determines the type of testicular cancer (seminoma or non-seminoma).
Chest X-ray or CT scan: To assess for potential metastasis (spread) to the lungs.
Abdominal and pelvic CT scan: To evaluate for lymph node involvement in the abdomen and pelvis.
Assessment:
Clinical suspicion of testicular cancer based on history and physical exam findings.
Confirmation of diagnosis based on pathology results of orchiectomy specimen.
Testicular cancer type (seminoma or non-seminoma).
Stage of testicular cancer (based on tumor size, lymph node involvement, and presence of distant metastasis).
Prognostic factors (age, tumor type, stage).
Plan:
Treatment: Discuss treatment options based on type, stage, and prognostic factors. This may include:
Surgery: Radical inguinal orchiectomy is typically performed initially.
Chemotherapy: Often used for non-seminoma or advanced stage seminoma.
Radiation therapy: May be used in certain cases, such as for lymph node involvement.
Surveillance: Active surveillance may be an option for stage 1 seminoma with close monitoring for signs of recurrence.
Follow-up: Schedule regular follow-up appointments for monitoring tumor markers, imaging studies, and potential late effects of treatment.
Patient Education: Educate the patient about testicular cancer, treatment options, potential side effects, and the importance of follow-up care.
Psychological Support: Discuss the emotional impact of a cancer diagnosis and offer support resources if needed.
Testicular Prosthesis: Inform the patient about the option of testicular prosthesis after orchiectomy.
Additional Notes:
Document any additional relevant information not covered above (e.g., referral to an urologist or oncologist).
Disclaimer: This template is for informational purposes only and should be adapted to fit the specific needs of each patient. It is important to follow established guidelines for the diagnosis, staging, and treatment of testicular cancer