Date:
Patient:
Reason for Visit:
Follow-up for prostate cancer
Evaluation of new symptoms (e.g., urinary problems, bone pain)
Treatment planning discussion
History:
Past Medical History (PMH):
Include any relevant medical conditions, such as hypertension, diabetes, or cardiovascular disease.
List any prior surgeries or procedures.
Medications:
List all current medications, including prescription and over-the-counter medications.
Note any medications that may interact with prostate cancer treatment.
Social History:
Tobacco use (history and current status)
Alcohol intake
Family history of prostate cancer or other relevant cancers
Presenting Complaint:
Describe the patient’s current concerns and symptoms, including onset, duration, and severity.
Examples: urinary frequency, hesitancy, urgency, nocturia, erectile dysfunction, bone pain, hematuria (blood in urine).
Prostatectomy History (if applicable):
Type of surgery (radical prostatectomy, robotic-assisted laparoscopic prostatectomy, etc.)
Date of surgery
Pathological findings (Gleason score, margin status, lymph node involvement)
Radiation Therapy History (if applicable):
Dates of radiation therapy
Dosage and treatment field
Acute and chronic side effects
Physical Exam:
General: Assess vital signs (blood pressure, heart rate, oxygen saturation) and overall health.
Genitourinary:
Palpate the prostate for size, consistency, and nodules.
Assess for inguinal lymphadenopathy (enlarged lymph nodes).
Neurological: Briefly assess for any neurological deficits if considering hormonal therapy.
Diagnostic Tests:
Prostate Specific Antigen (PSA): Current level and trends over time.
Imaging Tests (may be ordered depending on clinical presentation):
Digital Rectal Exam (DRE): Findings suggestive of prostate enlargement or nodules.
Transrectal Ultrasound (TRUS) with Biopsy (if PSA or DRE is abnormal): To diagnose or monitor prostate cancer.
Bone Scan: To assess for metastatic disease (spread of cancer to bones).
CT Scan or MRI: To further evaluate extent of local disease or metastatic spread.
Assessment:
Prostate cancer status: Confirmed, suspected, or in remission (based on history, physical exam, and diagnostic tests).
Disease stage and risk stratification (if applicable): Using tools like Gleason score, PSA level, and TNM staging system.
Treatment response (if applicable): Assess response to previous treatments (surgery, radiation) based on PSA levels, imaging, or clinical symptoms.
Presence of complications (if applicable): Urinary incontinence, erectile dysfunction, bowel problems
Plan:
Treatment plan: Discuss treatment options based on individual factors like disease stage, risk profile, overall health, and patient preferences.
Options may include:
Active surveillance (watchful waiting)
Surgery (radical prostatectomy, robotic surgery)
Radiation therapy (external beam, brachytherapy)
Hormone therapy (androgen deprivation therapy)
Other therapies (cryotherapy, high-intensity focused ultrasound)
Referral to specialists: Urologist, radiation oncologist, medical oncologist (depending on treatment plan).
Laboratory follow-up: Schedule for repeat PSA testing.
Imaging follow-up: Consider follow-up scans depending on treatment and risk factors.
Symptom management: Medications or therapies to manage urinary problems, erectile dysfunction, or bone pain.
Patient education: Provide information about prostate cancer, treatment options, potential side effects, and importance of follow-up.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of prostate cancer