Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for CML, evaluation of blood counts, treatment monitoring, or management of complications.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the following:
Presence of new or worsening symptoms (e.g., fatigue, fever, night sweats, bone pain)
Any recent illnesses or infections
Adherence to medications and potential side effects
Past Medical History:
Briefly summarize relevant past medical history, including:
Date of CML diagnosis
BCR-ABL1 mutation status (specific genetic abnormality in CML)
Sokalov score or EUTOS score (prognostic scoring systems)
Current phase of CML (chronic, accelerated, blast crisis)
Treatment history (tyrosine kinase inhibitors – TKIs)
Presence of co-morbidities (e.g., infections)
Social History:
Inquire about any occupational exposures to radiation or benzene (potential risk factors for CML).
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Physical Exam:
Assess for:
Splenomegaly (enlarged spleen)
Signs of infection (fever, pharyngitis)
Signs of bleeding (petechiae, ecchymoses)
Laboratory Tests (review recent results):
Complete blood count (CBC) with differential – assess for leukocytosis (elevated white blood cell count), anemia, or thrombocytopenia (low platelet count).
Monitor trends in white blood cell count and BCR-ABL1 levels over time.
BCR-ABL1 testing – a molecular test to quantify the specific genetic abnormality and monitor response to treatment.
Consider additional tests as indicated:
Blood tests to assess for infections.
Chest X-ray (if cough or shortness of breath are present).
Assessment (A):
Disease Phase:
Reassess the phase of CML (chronic, accelerated, blast crisis) based on current clinical features and laboratory findings.
Response to Treatment:
Evaluate response to TKI therapy based on:
Improvement in symptoms
Normalization of blood counts
Achievement of deep molecular response (minimal residual disease) as measured by BCR-ABL1 testing
Presence of Complications:
Assess for potential complications of CML (e.g., infections, bleeding) or side effects of TKI therapy.
Plan (P):
Treatment Plan:
Develop a treatment plan based on the phase of CML, response to therapy, and individual needs. Options may include:
Tyrosine Kinase Inhibitors (TKIs): First-line therapy for most CML patients.
Adjust TKI dose or switch to a different TKI based on response and tolerability.
Supportive Care: Management of infections, bleeding problems, and other complications.
Referral (if indicated):
Consider referral to a hematologist-oncologist for patients with complex CML or requiring advanced treatment options (e.g., bone marrow transplant).
Follow-up:
Schedule follow-up visits to monitor blood counts, BCR-ABL1 levels, response to treatment, and manage complications.
Define the frequency of follow-up based on the phase of CML, response to therapy, and presence of complications.
Patient Education:
Educate the patient about CML, its progression, and the rationale for the treatment plan.
Discuss the importance of adherence to medications and monitoring for side effects.
Explain the importance of maintaining good hygiene to prevent infections.
Provide information on the potential for long-term disease management with TKI therapy.
Offer resources for support groups or educational materials on managing CML.