Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for cholangiocarcinoma, evaluation of new or worsening symptoms, or post-treatment surveillance.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the reason for the visit. This may include:
For established diagnosis:
New or worsening symptoms suggestive of cholangiocarcinoma, such as:
Abdominal pain (right upper quadrant)
Jaundice (yellowing of the skin and eyes)
Pruritus (itching)
Fatigue
Dark urine
Light-colored stools
Weight loss
Any recent interventions or procedures (e.g., biliary drainage, surgery)
Response to previous treatment (chemotherapy, radiation)
For suspected diagnosis: Concerns about symptoms suggestive of cholangiocarcinoma.
Past Medical History:
Briefly summarize relevant past medical history, including:
Date of cholangiocarcinoma diagnosis (if applicable)
Type and location of cholangiocarcinoma (intrahepatic, extrahepatic, or hilar)
Stage of cholangiocarcinoma at diagnosis
Previous treatments received (surgery, chemotherapy, radiation)
Comorbid conditions that might influence treatment options
Social History:
Briefly inquire about risk factors for cholangiocarcinoma (if not previously documented):
Primary sclerosing cholangitis (PSC)
Ulcerative colitis
Chronic hepatitis B or C infection
Thorotrast exposure (industrial contrast agent)
Obesity
Smoking history
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Physical Exam:
Perform a focused physical exam to assess for:
Jaundice
Abdominal tenderness or masses
Hepatomegaly (enlarged liver)
Splenomegaly (enlarged spleen)
Ascites (fluid accumulation in the abdomen)
Peripheral lymphadenopathy (swollen lymph nodes)
Laboratory Tests (review recent results):
Liver function tests (LFTs) – may show abnormalities like elevated bilirubin, alkaline phosphatase
Tumor markers (CA 19-9) – can be elevated in cholangiocarcinoma but not specific
Coagulation studies (if considering surgery)
Other tests as indicated (e.g., complete blood count – CBC)
Imaging Studies (review recent results):
Briefly summarize findings from recent imaging studies, such as:
Liver ultrasound
CT scan with contrast
MRI scan with cholangiography (MRCP)
PET scan (if indicated)
Assessment (A):
Disease Status:
Based on clinical presentation, imaging studies, and laboratory findings, assess the current status of cholangiocarcinoma:
Stable disease
Progressive disease
Recurrent disease (if previously treated)
Treatment Response (if applicable):
Evaluate the response to previous treatment based on clinical and imaging findings.
Treatment Options (consider in consultation with other specialists):
Depending on the stage, location, and resectability of the tumor, discuss potential treatment options, including:
Surgical resection (curative or palliative)
Biliary drainage procedures
Chemotherapy
Radiation therapy
Targeted therapies (if applicable)
Palliative care for symptom management
Plan (P):
Treatment Plan:
Develop a treatment plan based on the assessment and in collaboration with the patient, considering their preferences and overall health status.
Diagnostic Tests (if needed):
Order additional tests to further evaluate the disease or guide treatment decisions.
Referral to Specialists (if indicated):
Consider referral to a surgical oncologist, radiation oncologist, medical oncologist, or other specialists for further evaluation and treatment.
Follow-up:
Schedule regular follow-up visits to monitor disease status, response to treatment, and manage symptoms.
Define the frequency of follow-up based on disease stage and treatment plan.
Patient Education:
Educate the patient about their cholangiocarcinoma, treatment options, potential side effects, and the importance of adhering to the treatment plan.
Discuss the prognosis and answer any questions or concerns.