Date: [DATE]
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for diffuse glioma
History of Present Illness: Briefly summarize the patient’s diagnosis of diffuse glioma, including:
Grade (WHO classification)
Location of tumor
Date of diagnosis
Prior treatment history (surgery, radiation, chemotherapy)
Current symptoms (headaches, seizures, cognitive changes, etc.)
Medications: List all current medications relevant to the patient’s glioma, including dosage and frequency.
Physical Exam:
Neurologic: Briefly describe the patient’s neurological exam, focusing on any new or worsening focal deficits.
Mental Status: Describe the patient’s mental status, including alertness, orientation, and cognitive function.
Imaging:
Summarize any recent brain MRI findings, including:
Size and location of the tumor
Presence of new enhancement
Any signs of edema or mass effect
Assessment:
Summarize the current status of the patient’s diffuse glioma.
State any changes in the patient’s clinical presentation or imaging findings.
Plan:
Outline the next steps in the patient’s care, including:
Repeat brain MRI in [timeframe]
Consideration of additional treatment options (surgery, radiation, chemotherapy) based on clinical and imaging findings
Referral to other specialists (neuro-oncology, palliative care, rehabilitation)
Discuss the importance of symptom management and supportive care
Prognosis: Briefly discuss the prognosis for diffuse glioma, considering factors such as grade, location, and extent of resection.
Education:
Document any patient education provided during the visit, such as information about the disease, treatment options, or potential side effects.
Follow-up:
Schedule the date for the next clinic visit.
Please note: This is a template and should be adapted to fit the specific needs of each patient.
Additional Information:
This template does not include specific details about the patient’s medical history or medications. You should consult the patient’s medical record for this information.
It is important to document the patient’s functional status and quality of life during each visit.
Always refer to current clinical practice guidelines for the management of diffuse glioma.