Date:
Patient:
MRN:
Clincian: (Medical Oncologist, Surgical Oncologist, Gastroenterologist)
Reason for Visit:
Follow-up for gastric cancer
Evaluation of symptoms and response to treatment (if applicable)
Review of imaging results
Treatment plan discussion
History of Present Illness:
Briefly describe the patient’s current status:
Time since diagnosis of gastric cancer
Presence and severity of any symptoms (abdominal pain, nausea, vomiting, early satiety, weight loss)
Current treatment regimen (surgery, chemotherapy, radiation therapy) and response to therapy
Past Medical History:
Gastrointestinal conditions (peptic ulcer disease, GERD) – may be risk factors
H. pylori infection (strong risk factor)
History of stomach surgery (may increase risk of certain types of gastric cancer)
Other medical conditions (important for treatment considerations)
Family History:
Family history of stomach cancer (increased risk factor)
Social History:
Smoking history (risk factor)
Diet (high intake of smoked foods, salted foods, red meat; low intake of fruits and vegetables – all potential risk factors)
Alcohol use (risk factor)
Physical Exam:
Vital Signs: May be normal or abnormal depending on the stage of cancer and presence of complications.
Abdominal: Palpation for masses or enlarged lymph nodes (may not be present in early stages).
Labs:
Tumor markers (CA 19-9, CEA): Elevated levels may be suggestive of gastric cancer, but not specific for diagnosis.
Complete Blood Count (CBC) – to assess for anemia or signs of infection.
Basic Metabolic Panel (BMP) – to assess overall health and kidney function (important for some medications).
Consider mentioning other labs ordered as needed based on suspicion of other conditions.
Imaging:
Previous imaging studies: Briefly describe the findings of the imaging studies used for diagnosis (endoscopy with biopsy, upper GI series, CT scan) at the time of diagnosis. This should include:
Location and size of the tumor
Lymph node involvement
Distant metastases (spread to other organs)
Current imaging studies: Describe the findings of any recent imaging studies used to monitor disease progression or assess response to treatment (CT scan, PET scan).
Assessment:
Summarize the current disease status based on symptoms, physical exam, labs, and imaging:
Stage of gastric cancer using a staging system (e.g., TNM staging system).
Treatment received and response to therapy (tumor shrinkage, improvement in symptoms).
Consideration of recurrence if applicable.
Plan:
Outline the treatment plan based on the assessment:
Surgery: Gastrectomy (partial or complete removal of the stomach) with possible lymph node dissection depending on the stage.
Chemotherapy: Adjuvant chemotherapy after surgery to reduce the risk of recurrence. May also be used in advanced stages or for palliative purposes.
Radiation therapy: May be used in combination with surgery or for palliative purposes (pain management in advanced stages).
Targeted therapy: Newer medications targeting specific cancer pathways may be used in specific situations.
Clinical trial participation: Discuss potential benefits and risks of participation.
Palliative care: Focus on symptom management and improving quality of life in advanced stages.
Prognosis:
Briefly discuss the prognosis. The prognosis for gastric cancer depends on the stage at diagnosis and response to treatment. Early-stage cancers have a better prognosis than advanced stages.
Emphasize the importance of regular follow-up to monitor for recurrence.
Education:
Document any education provided to the patient regarding:
The nature of gastric cancer, its stages, and treatment options
The potential side effects of treatment and how to manage them
The importance of regular follow-up and monitoring for recurrence
The emotional impact of a cancer diagnosis and available support resources
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about their condition.
Consider mentioning the importance of maintaining a healthy diet (fruits, vegetables, whole grains) as tolerated during treatment.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a medical oncologist, surgical oncologist, or gastroenterologist for diagnosis, treatment recommendations, and prognosis.