Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint: [Reason for visit – e.g., follow-up for liver metastasis, new symptoms like abdominal pain, jaundice]
History of Present Illness:
Briefly describe the reason for this visit.
For follow-up visits, inquire about any new or worsening symptoms since the last encounter (e.g., abdominal pain, nausea, vomiting, fatigue, weight loss, right upper quadrant tenderness).
For new symptom presentations, characterize them in detail (onset, duration, severity, aggravating/relieving factors).
Past Medical History:
Mention the known primary malignancy (cancer origin site) that has metastasized to the liver.
Include any previous treatments for the primary cancer.
List any relevant past medical history (e.g., diabetes, hypertension).
Medications:
List all current medications, including those for the primary cancer and any specific medications for the liver metastases (e.g., targeted therapies).
Social History:
Briefly inquire about current smoking habits.
Family History:
Mention any relevant family history of cancer.
Physical Exam:
Vital signs: Include temperature, pulse, respiratory rate, blood pressure.
Abdominal exam: Check for hepatomegaly (enlarged liver), right upper quadrant tenderness, and signs of ascites (fluid accumulation).
Jaundice assessment: Look for signs of jaundice in the skin and sclerae (whites of the eyes).
Laboratory Tests:
Mention relevant laboratory findings, including:
Liver function tests (LFTs): May show abnormalities in bilirubin, AST, ALT, and alkaline phosphatase.
Tumor markers (if applicable): Depending on the primary cancer, specific tumor markers may be elevated.
Complete blood count (CBC): May show anemia due to chronic illness or blood loss.
Imaging Studies (if performed):
Briefly describe findings from recent imaging studies, such as:
Liver ultrasound: Can assess the size, number, and location of liver metastases.
CT scan or MRI: May provide more detailed information about the size and location of metastases and their impact on surrounding structures.
PET scan (if applicable): Can help differentiate between benign and malignant lesions.
Assessment:
Diagnosis: Confirm the diagnosis of liver metastasis from the known primary malignancy.
Metastasis burden: Briefly describe the extent of liver involvement based on imaging studies (e.g., number, size, location of metastases).
Performance status: Mention the patient’s performance status using a scoring system (e.g., ECOG) to assess their overall health and ability to tolerate treatment.
Plan:
Treatment:
Outline the treatment plan based on the primary cancer type, extent of liver involvement, and the patient’s overall health. This may include:
Systemic therapy (chemotherapy, targeted therapy, immunotherapy): Treatment directed at the entire body to target cancer cells.
Local therapies (surgery, ablation): May be an option for patients with limited liver involvement and good performance status.
Palliative care: Focuses on symptom management and improving quality of life for patients with advanced disease.
Management of symptoms: Address any present symptoms like pain or nausea with appropriate medications.
Follow-up:
Schedule the next clinic visit for follow-up based on the treatment plan and disease progression.
Imaging studies will be repeated periodically to monitor response to treatment.