Date:
Patient:
MRN:
Clincian: (Hematologist, Rheumatologist, Oncologist) depending on underlying cause
Reason for Visit:
Follow-up for HLH
Evaluation of symptoms and response to treatment
Review of laboratory and imaging results
Assessment for complications
History of Present Illness:
Briefly describe the patient’s current status:
Persistence or improvement of symptoms (fevers, fatigue, weight loss, lymphadenopathy, hepatosplenomegaly)
Any new or worsening symptoms since last visit
Response to treatment (improvement in symptoms, laboratory findings)
Past Medical History:
Underlying cause of HLH (genetic predisposition, malignancy, autoimmune disease, infectious trigger)
Previous hospitalizations or treatments for HLH
Comorbid medical conditions
Family History:
Family history of HLH (suggests possible genetic predisposition)
Social History:
Recent infections or exposures (potential triggers)
Immunosuppressive medications (can increase risk)
Physical Exam:
Vital Signs:
Fevers are common.
Consider mentioning tachycardia (rapid heart rate) and tachypnea (rapid breathing) if present.
Lymphadenopathy (enlarged lymph nodes) and hepatosplenomegaly (enlarged liver and spleen) may be present on exam.
Skin exam: May reveal petechiae (red pinprick spots) due to bleeding abnormalities.
Labs:
Complete blood count (CBC):
Cytopenias (low red blood cell count, low white blood cell count, low platelet count)
Liver function tests (LFTs):
Elevated liver enzymes may be present.
Ferritin:
Elevated ferritin levels are a hallmark feature of HLH.
Triglycerides:
May be elevated.
Bone marrow aspiration and biopsy:
Hemophagocytosis (immune cells engulfing blood cells) is diagnostic.
Consider mentioning other labs ordered as needed (viral serologies, autoimmune workup).
Imaging:
Chest X-ray:
May show signs of lung infiltrates (fluid buildup).
Other imaging studies (CT scan, MRI) may be used to assess specific organs or rule out other diagnoses.
Assessment:
Summarize the diagnosis of HLH based on clinical presentation, laboratory findings, and bone marrow examination.
Identify the underlying cause of HLH (if known).
Assess the response to treatment and disease activity.
Plan:
Outline the treatment plan based on the underlying cause and severity of HLH:
Immunosuppressive therapy:
Corticosteroids are often used to suppress the overactive immune response.
Other immunosuppressants may be used depending on the specific cause.
Directed therapy:
Treatment directed at the underlying cause (e.g., chemotherapy for malignancy, antibiotics for infection).
Supportive care:
Management of cytopenias (blood transfusions, growth factors)
Management of fever and inflammation
Prognosis:
Briefly discuss the prognosis. Prognosis depends on the underlying cause and response to treatment. HLH can be a life-threatening condition, but early diagnosis and treatment can improve outcomes.
Education:
Document any education provided to the patient regarding:
The nature of HLH, its underlying cause, and potential complications
The importance of adhering to treatment plan and monitoring for side effects
The importance of recognizing and reporting any new or worsening symptoms
The potential long-term management needs depending on the underlying cause
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about side effects, long-term prognosis, or impact on daily life.
Consider the emotional impact of chronic illness and offer support or referral for mental health services if needed.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a hematologist, rheumatologist, or oncologist depending on the underlying cause for diagnosis, treatment recommendations, and prognosis.