Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint: Briefly describe the patient’s main reason for this visit. This could include:
Painless lymphadenopathy (swollen lymph nodes) – common in neck, armpits, or groin
Fever, chills, night sweats (B symptoms)
Unexplained weight loss or fatigue
Itching (less common)
History of Present Illness:
Onset and duration of symptoms
Location, size, and characteristics of swollen lymph nodes
Presence of B symptoms and their duration
Any recent illnesses or infections
Past Medical History:
Prior diagnoses (autoimmune diseases, infections)
Medications (current and recent)
History of exposure to radiation or chemotherapy
Family History:
History of Hodgkin’s lymphoma or other cancers in first-degree relatives
Social History:
Occupational exposures (e.g., chemicals, herbicides)
Physical Examination:
General appearance (illness, malnutrition)
Palpation of lymph nodes (size, consistency, tenderness)
Spleen and liver exam (may be enlarged in some cases)
Laboratory Tests:
Complete blood count (CBC) – may show anemia, low white blood cells, or elevated lymphocytes
Liver function tests – to assess overall health
LDH (lactate dehydrogenase) – may be elevated in advanced stages
HIV test (routine screening)
Imaging Studies:
Chest X-ray – may show enlarged mediastinal lymph nodes
CT scan (chest, abdomen, pelvis) – to assess extent of lymph node involvement
PET scan (positron emission tomography) – to identify metabolically active lymphoma cells (often used for staging)
Bone Marrow Biopsy:
Gold standard for diagnosis – examines bone marrow for presence of Hodgkin’s lymphoma cells
Diagnosis:
Suspected Hodgkin’s lymphoma (based on symptoms and physical exam)
Hodgkin’s lymphoma (specify subtype based on biopsy)
Stage of Hodgkin’s lymphoma (determined by extent of disease)
Treatment Plan:
Depends on stage and subtype of Hodgkin’s lymphoma
Typically involves chemotherapy with or without radiation therapy
Clinical trial participation may be an option
Prognosis:
Discuss the outlook based on stage, subtype, and response to treatment. Hodgkin’s lymphoma is highly curable with early diagnosis and treatment.
Importance of regular follow-up to monitor for recurrence.
Patient Education:
Explain Hodgkin’s lymphoma and the cause
Importance of completing the entire treatment plan
Potential side effects of treatment and how to manage them
Importance of maintaining a healthy lifestyle
Support groups and resources available for people with Hodgkin’s lymphoma
Next Follow-up:
Schedule for the next appointment to monitor response to treatment, address any side effects, and assess for potential complications.