Date:
Patient:
MRN:
Clincian: (Obstetrician, Gynecological Oncologist)
Reason for Visit:
Follow-up for gestational trophoblastic disease (GTD)
Evaluation of hCG levels and imaging results
Discussion of treatment plan and surveillance
History of Present Illness:
Briefly describe the patient’s current status:
Type of GTD diagnosed (complete mole, partial mole, gestational trophoblastic neoplasia (GTN))
Date of diagnosis and initial management (eVACuation of products of conception (D&C), surgical evacuation)
Current hCG levels and trend (rising, plateau, falling)
Presence of any symptoms (vaginal bleeding, pelvic pain)
Past Medical History:
Underlying risk factors for GTD (age > 35, previous history of GTD)
Past obstetric history (miscarriage, molar pregnancy)
Family History:
Not typically relevant for GTD
Social History:
Not typically relevant for GTD
Physical Exam:
Pelvic exam: May be normal or reveal signs of residual trophoblastic tissue.
Labs:
hCG (human chorionic gonadotropin) levels: Serial monitoring of hCG is crucial for diagnosis, treatment monitoring, and surveillance after treatment.
Consider mentioning other labs ordered as needed based on suspicion of complications (complete blood count – CBC).
Imaging:
Pelvic ultrasound: Used for initial diagnosis, evaluation of uterine involution, and detecting residual trophoblastic tissue.
Chest X-ray or CT scan: May be used to assess for metastatic disease (in cases of suspected GTN).
Assessment:
Summarize the diagnosis and current disease status:
Confirmation of GTD type based on pathology results and hCG levels.
Stage of GTD (based on FIGO staging system for GTN) if applicable.
Response to treatment based on hCG trends and imaging findings.
Plan:
Outline the treatment plan based on the assessment:
Follow-up and surveillance: Close monitoring of hCG levels with frequent follow-up visits is essential for all GTD patients after initial treatment.
Chemotherapy: Used for treatment of GTN and some high-risk cases of choriocarcinoma.
Hysterectomy: May be considered in some cases, especially with high-risk factors or recurrent disease.
Consider mentioning the importance of contraception during the surveillance period.
Prognosis:
Briefly discuss the prognosis. The prognosis for GTD depends on the type and stage of the disease. Complete mole and partial mole have excellent cure rates with proper management. The prognosis for GTN is good with treatment, but depends on the stage and risk factors.
Emphasize the importance of adhering to the follow-up schedule for early detection of any recurrence.
Education:
Document any education provided to the patient regarding:
The nature of GTD, its types, and risk factors
The importance of follow-up appointments and hCG monitoring
The potential side effects of treatment options (if applicable)
The emotional impact of GTD 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 fertility, future pregnancy, or potential complications.
Consider the emotional well-being of the patient and offer support or referral for mental health services if needed.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with an obstetrician or gynecological oncologist for diagnosis, treatment recommendations, and prognosis.