Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Reason for Visit:
Document the reason for this visit. Is this a newly diagnosed case, a follow-up visit after treatment, or a visit to address specific symptoms?
History of Present Illness:
For newly diagnosed cases:
Onset, duration, and character of any abnormal vaginal bleeding (e.g., postmenopausal bleeding, heavy menstrual bleeding).
Pelvic pain
Vaginal discharge (unusual color or odor)
Risk factors:
Age (most common in postmenopausal women)
Obesity
Unopposed estrogen therapy
Tamoxifen use (breast cancer treatment)
Lynch syndrome (hereditary cancer predisposition)
Personal or family history of endometrial cancer or other gynecological cancers
For follow-up visits:
Summarize the prior diagnosis and treatment received.
Inquire about any new or worsening symptoms.
Follow-up on any specific concerns from the previous visit.
Past Medical History:
Briefly document any relevant past medical conditions, surgeries, or allergies, especially those affecting the uterus or ovaries, or any medical conditions influencing treatment options.
Social History:
Tobacco use (increases risk of endometrial cancer)
Body mass index (BMI)
Medications:
List all current medications, including any hormonal therapies.
Allergies:
Document any known allergies, especially allergies to medications used in treatment.
Family History:
Inquire about a family history of endometrial cancer, other gynecological cancers, or Lynch syndrome.
Physical Exam:
Vital Signs: Include blood pressure.
Pelvic Exam:
Assess for uterine enlargement or friability.
Consider Pap smear if not done recently (to rule out cervical cancer).
Laboratory:
Document any laboratory tests performed, such as:
Complete blood count (CBC): May show anemia if there is significant blood loss.
Serum CA-125: This tumor marker can be elevated in some cases of endometrial cancer, but it is not specific for this diagnosis.
Imaging:
Endometrial biopsy: The gold standard for diagnosis. A sample of the endometrium is obtained for microscopic examination.
Transvaginal ultrasound: May be used to assess endometrial thickness and identify any abnormalities.
Abdominal/pelvic CT scan or MRI: May be helpful for staging the cancer (determining the extent of spread) and planning treatment.
Assessment:
Suspected endometrial cancer: Based on clinical presentation and ongoing evaluation (if biopsy not yet performed).
Endometrial cancer diagnosed (stage): If biopsy confirms the diagnosis, document the stage of cancer based on the FIGO staging system (extent of spread).
Endometrial hyperplasia: A benign thickening of the endometrium that may require further monitoring or treatment depending on the type.
Consider differential diagnoses based on symptoms (e.g., benign uterine fibroids, cervical cancer).
Plan:
The treatment plan will depend on the stage and grade of the cancer, as well as the patient’s overall health and preferences.
Discuss treatment options with the patient, which may include:
Surgery: The most common treatment, typically involving a hysterectomy (removal of the uterus) with or without removal of the ovaries and fallopian tubes.
Hormonal therapy: May be used in some cases, particularly for early-stage cancer or in patients not suitable for surgery.
Radiation therapy: May be used in combination with surgery or as adjuvant therapy (after surgery) to reduce the risk of recurrence.
Address any anxiety or concerns the patient may have about diagnosis and treatment options.
Follow-up:
The follow-up schedule will depend on the treatment received and the stage of the cancer.
Close monitoring with pelvic exams, imaging studies, and potentially tumor markers may be needed to monitor for recurrence.
Provide resources for support groups and educational materials on endometrial cancer.
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant details regarding symptoms, risk factors, physical exam findings, laboratory and imaging results, stage (if diagnosed), and individualized treatment plan.