Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Evaluation of chemotherapy- and radiotherapy-induced nausea and vomiting (CINV).
SOAP
Subjective (S):
History of Present Illness:
Inquire about the following:
Onset, duration, and frequency of nausea and vomiting episodes
Severity of nausea (rated on a standardized scale if possible)
Presence of other symptoms (e.g., dry mouth, constipation, fatigue)
Impact on daily activities and quality of life
Recent chemotherapy and/or radiotherapy regimen and schedule
Use of antiemetic medications (medications to prevent nausea and vomiting) and their effectiveness
Past Medical History:
Briefly summarize relevant past medical history, including:
Underlying malignancy and current treatment plan
Previous history of CINV with prior chemotherapy or radiotherapy
Other medical conditions that might contribute to nausea and vomiting (e.g., gastroparesis)
Allergies to antiemetic medications
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Physical Exam:
Perform a focused physical exam to assess for dehydration (e.g., dry mucous membranes, poor skin turgor) if vomiting is frequent.
Assessment (A):
CINV Type:
Based on the timing of symptoms relative to chemotherapy or radiotherapy, classify the CINV type:
Acute CINV (within 0-24 hours)
Delayed CINV (1-5 days after treatment)
Anticipatory CINV (associated with anxiety before treatment)
Severity of CINV:
Assess the severity of CINV based on the frequency and volume of vomiting, impact on daily activities, and need for hospitalization.
Plan (P):
Antiemetic Prophylaxis:
Implement a prophylactic antiemetic regimen based on the type and expected severity of CINV, using a combination of medications from different classes:
5-HT3 antagonists (e.g., ondansetron)
NK1 receptor antagonists (e.g., aprepitant)
Steroids (e.g., dexamethasone)
Cannabinoids (dronabinol) may be considered in some cases
Rescue Medications:
Prescribe rescue medications for breakthrough nausea and vomiting episodes.
Hydration Management:
Assess hydration status and consider intravenous fluids if dehydration is present.
Encourage frequent oral hydration with small sips of clear liquids.
Nutritional Support:
If nausea and vomiting significantly impact oral intake, consider dietary modifications (bland foods) or nutritional support options (enteral feeding) in consultation with a nutritionist.
Patient Education:
Educate the patient about CINV, risk factors, and the importance of adhering to the antiemetic regimen.
Provide instructions on managing nausea and vomiting at home, including dietary modifications and relaxation techniques.
Encourage communication with the healthcare team for any worsening of symptoms or concerns.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., oncologist, pharmacist)
Discussion of potential medication side effects and monitoring plan
Importance of early intervention for symptom control and preventing complications (e.g., dehydration, electrolyte imbalance)