Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for chordoma, 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 chordoma, such as:
Pain (may be dull, aching, or radicular depending on location)
Mass in the affected area
Neurologic symptoms (numbness, weakness, bowel or bladder dysfunction) if the tumor involves nerves or the spinal cord
Headaches (if skull base chordoma)
Difficulty swallowing (if sacral chordoma)
Response to previous treatment (surgery, radiation therapy)
For suspected diagnosis: Concerns about a tumor based on symptoms or imaging findings in a typical location for chordoma (sacrum, skull base, spine).
Past Medical History:
Briefly summarize relevant past medical history, including:
Date of chordoma diagnosis (if applicable)
Location of chordoma (sacrum, skull base, spine)
Histologic subtype (conventional, chondrosarcomatous, dedifferentiated)
Previous surgeries or biopsies
Radiation therapy history
Comorbid conditions that might influence treatment options
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Neurologic Exam (if applicable):
Assess for neurologic deficits (motor weakness, sensory changes) that may indicate nerve involvement.
Physical Exam:
Perform a focused physical exam to assess the affected area, including:
Location and size of the mass (if palpable)
Tenderness to palpation
Limited range of motion (if applicable)
Imaging Studies (review recent results):
Briefly summarize findings from recent imaging studies, such as:
MRI scan (essential for diagnosis, shows extent of tumor and involvement of surrounding structures)
CT scan with contrast (may be helpful for preoperative planning)
PET scan (may be used to assess for spread of aggressive tumors)
Assessment (A):
Disease Status:
Based on clinical presentation, imaging studies, and past pathology (if available), assess the current status of chordoma:
Stable disease
Progressive disease
Recurrent disease (if previously treated)
Treatment Response (if applicable):
Evaluate the response to previous treatment based on clinical presentation, imaging studies, and neurologic function.
Treatment Options (consider in consultation with other specialists):
Depending on the location, size, and aggressiveness of the tumor, discuss potential treatment options, including:
Surgery: The primary treatment for chordoma whenever feasible, aiming for complete or gross-total resection.
Radiation therapy: May be used before or after surgery, for palliative purposes, or for inoperable tumors.
Proton therapy: A type of radiation therapy that may be more precise and have fewer side effects for some tumors.
Targeted therapy: Newer medications targeting specific pathways involved in tumor growth are being investigated.
Prognosis:
Provide a general estimate of prognosis based on the specific characteristics of the chordoma, treatment response, and the patient’s overall health.
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 (e.g., biopsy for definitive diagnosis if not previously performed).
Referral to Specialists (if indicated):
Consider referral to a surgical oncologist, radiation oncologist, medical oncologist, or neurosurgeon 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 characteristics, treatment plan, and response.
Patient Education:
Educate the patient about chordoma, specific location and type, treatment options, potential side effects, and the importance of adhering to the treatment plan.
Discuss the prognosis and answer any questions or concerns.
Provide information about support groups or resources for patients with chordoma.