Date:
Patient:
Reason for Visit:
Follow-up for rectal cancer
Assessment of treatment response and side effects
Evaluation for recurrence
History:
Presenting Illness:
Date of rectal cancer diagnosis
Initial symptoms (e.g., rectal bleeding, change in bowel habits, tenesmus)
Tumor location and stage at diagnosis
Prior treatment details (surgery, radiation, chemotherapy)
Current symptoms and any changes since last visit
Past Medical History (PMH):
Underlying medical conditions
Prior surgeries (abdominal or pelvic)
Family history of cancer
Social History:
Smoking history (significant risk factor)
Diet and exercise habits
Physical Exam:
General: Assess for signs of weight loss, malnutrition, or anemia.
Abdominal: Palpate for abdominal masses or tenderness.
Digital rectal exam (DRE): Evaluate for rectal masses, strictures, or recurrence.
Diagnostic Tests (may be ordered depending on clinical presentation):
Complete Blood Count (CBC): May show anemia if chronic blood loss is present.
Carcinoembryonic Antigen (CEA): Tumor marker that can be elevated in some rectal cancers, but not specific for recurrence.
Imaging Tests:
CT scan or MRI of the pelvis and abdomen: Assess for tumor size, lymph node involvement, and potential recurrence.
PET scan (may be used): Can help identify metabolically active cancer cells suggestive of recurrence.
Colonoscopy: May be performed to visualize the rectum and surrounding tissues for signs of recurrence or new polyps.
Assessment:
Treatment response: Evaluate response to surgery, radiation, and/or chemotherapy based on imaging and clinical findings.
Presence of recurrence: Based on clinical suspicion, diagnostic test results, and biopsy confirmation (if necessary).
Stage of recurrence (if applicable): Local, regional, or distant recurrence.
Side effects of treatment: Assess for ongoing issues related to surgery (e.g., bowel dysfunction, sexual dysfunction), radiation (e.g., radiation proctitis), or chemotherapy.
Plan:
Management of recurrence (if applicable): Discuss potential treatment options based on the stage and location of recurrence (surgery, radiation, chemotherapy, or palliative care).
Management of treatment side effects: Address ongoing issues with medications, dietary modifications, physical therapy, or other supportive measures.
Surveillance for recurrence: Schedule for follow-up appointments and diagnostic tests (e.g., CEA, imaging) to monitor for potential recurrence.
Referral to an oncologist: For complex cases, treatment decisions regarding recurrence, or management of side effects.
Referral to a palliative care specialist: For patients with advanced or recurrent disease to provide symptom management and improve quality of life.
Patient education: Provide information about the follow-up plan, potential signs and symptoms of recurrence, importance of maintaining a healthy lifestyle, and management of treatment side effects.
Discuss the emotional aspects of living with cancer and available support resources.
Follow-up:
Schedule for follow-up appointments based on the risk of recurrence:
More frequent visits for patients with higher risk or on active treatment for recurrence.
Less frequent visits for patients with no evidence of recurrence.
Discuss the importance of ongoing communication regarding any new symptoms or concerns.
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 rectal cancer