Patient: [Patient Name]
Date: [Date of Encounter]
I. History of Present Illness:
Date of colon cancer diagnosis (if applicable):
Presenting symptoms (select all that apply):
Change in bowel habits (diarrhea, constipation, bloody stools)
Abdominal pain or cramping
Rectal bleeding
Unexplained weight loss
Fatigue
Iron deficiency anemia
Family history of colon cancer or other GI malignancies: (yes/no) – If yes, specify details (degree of relation, type of cancer)
Previous colonoscopy results (if any): (normal, polyps, previous cancer)
II. Past Medical History:
Inflammatory bowel disease (IBD): (Ulcerative colitis, Crohn’s disease)
Other relevant medical conditions (diabetes, obesity)
Smoking history: (current smoker, former smoker, never smoker)
III. Social History:
Diet (high in red meat, processed foods, low in fiber)
Alcohol intake:
Physical activity level:
IV. Physical Exam:
Vital signs: (BP, HR, RR, Temp)
Abdominal exam: (palpable masses, tenderness)
Rectal exam: (blood on stool, rectal mass)
V. Assessment:
Stage of colon cancer (if diagnosed): (based on TNM staging system)
Location of tumor: (right colon, left colon, rectum)
Metastatic spread (suspected or confirmed): (lymph nodes, other organs)
Performance status (functional limitations due to cancer)
VI. Diagnostic Studies (if applicable):
Colonoscopy: (visualization and biopsy of tumor)
CT scan of abdomen and pelvis: (tumor size, lymph node involvement)
Other tests (if indicated):
CEA (carcinoembryonic antigen) blood test: (tumor marker)
PET scan: (detecting distant metastases)
Genetic testing (Lynch syndrome)
VII. Plan:
Treatment plan (based on stage and other factors):
Surgery (type of surgery planned, extent of resection)
Adjuvant chemotherapy or radiation therapy (if indicated)
Targeted therapy (if applicable)
Clinical trial participation (consideration)
Supportive care: (pain management, nutritional counseling)
Follow-up plan: (surveillance for recurrence, schedule for imaging and blood tests)
Palliative care (for advanced or metastatic disease)
VIII. Notes:
Include any additional relevant information, such as patient’s understanding of diagnosis and treatment options, emotional well-being, and need for social support.
IX. Resources:
Consider providing patient education materials on colon cancer from reputable sources (e.g., American Cancer Society, National Cancer Institute).