Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint: Briefly state the patient’s main reason for this visit. Does it relate to HHT symptoms (e.g., epistaxis, GI bleeding) or follow-up for management?
History of Present Illness:
Date of HHT diagnosis (if known)
Current symptoms related to HHT (location, frequency, severity)
Any recent changes in symptoms or bleeding episodes
Management strategies currently employed (medications, embolization)
Past Medical History:
Comorbid conditions (e.g., anemia, iron deficiency)
Surgeries or hospitalizations related to HHT bleeding
Medications (prescription and over-the-the-counter) relevant to HHT or bleeding
Allergies
Family History:
History of HHT in first-degree relatives
Other relevant medical conditions in family members (e.g., pulmonary AVMs)
Social History:
Medications or supplements that may increase bleeding risk (e.g., NSAIDs)
Pregnancy history (if applicable)
Physical Examination:
General appearance (signs of anemia)
Presence and location of visible telangiectasias (mucosal, skin)
Signs of chronic blood loss (e.g., pallor)
Cardiopulmonary exam (if pulmonary AVM suspected)
Laboratory Tests:
Complete blood count (CBC) with iron studies (to assess for anemia)
Coagulation profile (if indicated)
Imaging Studies:
Brain MRI/MRA (if neurological symptoms or family history suggestive of cerebral AVMs)
Chest X-ray or CT scan (if pulmonary AVM suspected)
Endoscopy (GI or nasal) to identify bleeding sites (if indicated)
Diagnosis:
Confirmed hereditary hemorrhagic telangiectasia
Suspected hereditary hemorrhagic telangiectasia (if workup ongoing)
Treatment Plan:
Medications to control bleeding (e.g., tranexamic acid, hormonal therapy)
Minimally invasive procedures (laser ablation, embolization) for targeted telangiectasia
Surgical intervention (if indicated, e.g., for severe epistaxis)
Iron supplementation (if iron deficiency present)
Prophylaxis for future bleeding episodes
Prognosis:
Discuss the long-term outlook with management
Importance of adherence to treatment and regular monitoring
Patient Education:
Explain HHT and the risk of bleeding
Importance of following the treatment plan and medications
Techniques to manage nosebleeds or other bleeding episodes
Warning signs and symptoms to watch for
Importance of regular follow-up and preventive care
Next Follow-up:
Schedule for the next appointment
Note: This is a template and may need to be adapted based on the specific patient and their situation. Additionally, terminology is provided in Chinese characters for reference.