Date:
Patient:
MRN:
Clinician: (Gastroenterologist, Primary Care Physician)
Reason for Visit:
Follow-up for gallbladder polyps
Evaluation of symptoms (if applicable)
Review of imaging results
Discussion of surveillance plan
History of Present Illness:
Briefly describe the patient’s current status:
Time since diagnosis of gallbladder polyps
Presence and severity of any symptoms (abdominal pain, nausea, vomiting, right upper quadrant tenderness) – may be present but not specific to polyps
Change in symptoms since initial diagnosis
Past Medical History:
Underlying conditions (e.g., obesity, hyperlipidemia) that may increase risk of gallstones
History of cholecystitis (gallbladder inflammation) or pancreatitis
Family History:
Family history of gallstones (increased risk factor)
Social History:
Not typically relevant for gallbladder polyps, but may include diet habits (high-fat diet may increase risk of gallstones)
Physical Exam:
Vital Signs: (may be normal unless there are co-existing conditions)
Abdominal: Palpation for right upper quadrant tenderness (may suggest co-existing cholecystitis).
Labs:
Labs are not routinely used for diagnosis of gallbladder polyps, but may be performed to rule out other conditions:
Liver function tests (LFTs) – to assess for underlying liver disease or co-existing cholecystitis.
Consider mentioning other labs ordered as needed based on suspicion of other conditions.
Imaging:
Previous imaging studies: Briefly describe the findings of the imaging study (abdominal ultrasound) that identified the gallbladder polyps. This should include:
Number, size, and location of the polyps.
Current imaging studies: May be repeated depending on the size and initial presentation:
If no symptoms and polyps are small (< 6mm), consider mentioning the plan for surveillance with ultrasound at intervals (usually 1-2 years).
If symptoms are present or polyps are larger (> 10mm), repeat ultrasound or consider referral for additional imaging (HIDA scan) to assess gallbladder function.
Assessment:
Summarize the current status based on symptoms, physical exam, and imaging:
Presence and characteristics of gallbladder polyps.
Correlation of symptoms with polyps (if any).
Assessment of gallbladder function (if additional imaging was performed).
Plan:
Outline the management plan based on the assessment:
Surveillance: For small polyps (< 6mm) with no symptoms, recommend ultrasound follow-up at intervals (usually 1-2 years) to monitor for growth.
Surgical intervention: Consider cholecystectomy (gallbladder removal) for:
Larger polyps (> 10mm)
Symptomatic polyps (even if small)
Polyps with suspicion of malignancy (very rare)
Referral to a gastroenterologist for further evaluation and management if indicated.
Education:
Document any education provided to the patient regarding:
The nature of gallbladder polyps and their prevalence
The potential risks associated with gallbladder polyps (inflammation, malignancy – very rare)
The importance of following a healthy diet to potentially reduce the risk of future gallstone formation
The rationale for surveillance or surgical intervention depending on the situation
Prognosis:
Briefly discuss the prognosis. Gallbladder polyps are usually benign, but there is a small risk of malignancy.
Regular follow-up with ultrasound is important to monitor for changes in size or development of symptoms.
Surgical intervention offers a definitive treatment for symptomatic polyps or those with concerning features.
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and management plan, and any concerns they may have.
Consider mentioning the importance of seeking medical attention if they experience abdominal pain, nausea, or vomiting, which could suggest complications like cholecystitis.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a healthcare professional for diagnosis, treatment recommendations, and prognosis.