Colorectal Surgeon Template

Colorectal Cancer Consult

A professional Colorectal Surgeon template for healthcare professionals.

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Specialty

Colorectal Surgeon

Used

61 times

Type

Note

Last edited

5/22/2025

Created by

Nathalie Wong-Chong

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About this template

This colorectal cancer consult template is designed for colorectal surgeons to document patient consultations effectively. It includes sections for patient demographics, diagnosis, symptoms, medical history, family history, and examination findings. The template also covers investigations, impression, and treatment plans, ensuring comprehensive documentation. Ideal for use in Heidi, this template streamlines the process of recording detailed patient information, aiding in the management of colorectal cancer cases. It is particularly useful for documenting complex cases requiring multidisciplinary input and ongoing treatment planning.

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I had the pleasure of seeing John Smith on 1 November 2024. He is a 62-year-old male seen today with his wife. He has been recently diagnosed with stage IIIB colorectal cancer. The patient reports abdominal pain for 3 months. The patient denies weight loss. The patient reports changes in bowel habits and fatigue. He has a 5-year history of type 2 diabetes, which may have worsened over the past year. This was his third colonoscopy. He had a CT scan in 2023 which was inconclusive. Family History: Father had colon cancer at age 70. Surgical/Medical History: Appendectomy in 1990, hypertension. Procedures: Colonoscopy (Dr. Thomas Doe - 1 November 2024): Large mass in the sigmoid colon. Known Allergies: Penicillin Medications: Metformin, Lisinopril Lifestyle Notes: Non-smoker, occasional alcohol use Investigations: Blood Test (1 November 2024): Elevated CEA levels Normal liver function Anemia Normal kidney function Elevated glucose MRI (1 November 2024): Mass in sigmoid colon No metastasis Oncology: Previous chemotherapy for colon cancer in 2022 Examination: Clinical examination demonstrated tenderness in the lower abdomen. There was evidence of a palpable mass. Rectal examination was normal. He has pallor and mild dehydration. He has absence of lymphadenopathy. Impression/Plan: I have ordered the following: PET scan and biopsy to assess the extent of the disease, in case he requires further chemotherapy. His case will be presented at the oncology board meeting. He has a stage IIIB colorectal cancer. Although the mass is large, it appears localized. I am not sure he will need surgery. He is a suitable surgical candidate. He was quite anxious and had several questions today, which were answered. I will refer him to oncology to get their formal opinion regarding chemotherapy, in the interim. I have suggested a treatment plan involving possible surgery and chemotherapy. I will see him next following these investigations. If he does not need surgery, we will plan for chemotherapy in 2 weeks. My office will be in touch with John Smith. Thank you for involving me in his care. (45 min)