Date:
Patient:
MRN:
Clincian: (Hepatologist, Oncologist)
Reason for Visit:
Follow-up for known HCC
Review of imaging studies and tumor markers
Discussion of treatment plan and surveillance strategies
History of Present Illness:
Briefly describe current symptoms (may be absent in early stages):
Abdominal pain (right upper quadrant)
Early satiety or weight loss
Fatigue
Jaundice (yellowing of the skin and eyes)
Ascites (fluid accumulation in the abdomen)
Mention date of initial HCC diagnosis and suspected risk factors (cirrhosis, hepatitis B/C infection, etc.).
Past Medical History:
Underlying liver disease (cirrhosis is the major risk factor)
Previous treatments for HCC or underlying liver disease
Other relevant medical history (e.g., diabetes)
Social History:
Alcohol and tobacco use (contributing risk factors)
Family history of liver disease or cancer
Physical Exam:
Vital Signs: May be normal or show signs of decompensated liver disease (fever, ascites).
Jaundice (icterus) on skin and sclerae.
Hepatomegaly (enlarged liver) with possible nodules on palpation.
Consider mentioning signs of ascites on abdominal exam.
Labs:
Liver function tests (LFTs):
May show abnormalities suggestive of underlying liver disease and possible tumor burden.
Alpha-fetoprotein (AFP):
Elevated AFP levels can be a tumor marker for HCC, but not specific.
Consider mentioning other labs ordered as needed (complete blood count, coagulation studies).
Imaging:
Imaging studies are crucial for diagnosis, staging, and treatment planning:
Liver ultrasound with contrast
CT scan with contrast
MRI scan with contrast (may be helpful in some cases)
Mention the size, location, and number of tumors identified on imaging.
Consider mentioning the Barcelona Clinic Liver Cancer (BCLC) staging system used to classify HCC based on tumor size, number, vascular invasion, and liver function.
Assessment:
Summarize the diagnosis of HCC based on imaging studies and, if available, elevated AFP levels.
State the BCLC stage of the HCC.
Discuss the overall performance status of the patient.
Plan:
Outline the treatment plan based on the BCLC stage, performance status, and underlying liver function:
Curative-intent therapies:
Surgical resection (if tumor is solitary and confined to the liver)
Liver transplantation (for select cases with good liver function and small tumors)
Ablation therapies (radiofrequency ablation, microwave ablation) for localized tumors.
Locoregional therapies:
Transarterial chemoembolization (TACE) for intermediate-stage HCC to slow tumor growth.
Systemic therapies:
Sorafenib (targeted therapy) for advanced-stage HCC to improve survival.
Supportive care:
Management of underlying liver disease and complications (ascites).
Consider mentioning the need for referral to a multidisciplinary team for treatment planning.
Prognosis:
Briefly discuss the prognosis. Prognosis depends on the stage of HCC at diagnosis, underlying liver function, and response to treatment.
Early-stage HCC treated with curative intent can have good outcomes.
Advanced-stage HCC has a poorer prognosis but treatment can improve survival.
Education:
Document any education provided to the patient regarding:
The nature of HCC and its risk factors
The importance of adhering to the treatment plan
Potential side effects of treatment options
The importance of regular follow-up and surveillance for recurrence
Palliative care options for advanced disease
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 treatment side effects, prognosis, or advance care planning.
Address the potential emotional impact of a cancer diagnosis 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 a hepatologist, oncologist, or other specialists involved in the patient’s care for diagnosis, treatment recommendations, and prognosis.