Subjective
Date of visit
Reason for visit (initial evaluation for suspected PV, follow-up for diagnosed PV)
History of present illness:
Symptoms (may be absent in early stages):
Headache
Dizziness
Fatigue
Pruritus (itching) – especially after a hot shower or bath (aquagenic pruritus)
Erythromelalgia (burning pain in hands and feet) – less common
Splenomegaly (enlarged spleen) – may cause discomfort in left upper abdomen
Duration of symptoms
Past medical history (relevant conditions, previous treatments for PV)
Family history (presence of PV in first-degree relatives)
Medications (current medications, including phlebotomy or cytoreductive medications)
Allergies
Objective
Vital signs (temperature, heart rate, blood pressure) – may be elevated due to increased blood viscosity
Physical exam:
General (assessing for signs of plethora – ruddy complexion, engorged blood vessels)
Splenomegaly palpation (if present)
Neurological exam (checking for reflexes, cognitive function)
Assessment
Suspected polycythemia vera based on clinical presentation and laboratory findings
Diagnostic workup (may include some of the following):
Complete blood count (CBC) – elevated hematocrit (red blood cell volume) is a key finding
Blood tests:
Erythropoietin (EPO) level – usually low or suppressed in PV (distinguishing it from secondary erythrocytosis)
JAK2 mutation testing (genetic test helpful in diagnosing PV)
Bone marrow biopsy (may be performed to confirm diagnosis and assess for fibrosis)
Plan
Definitive diagnosis based on a combination of clinical features, laboratory findings, and bone marrow biopsy
Treatment (aimed at reducing blood cell count and preventing complications):
Phlebotomy (removal of excess blood) – the mainstay of treatment for most patients
Cytoreductive medications (hydroxyurea, interferon) – used to suppress bone marrow activity in some cases
Low-dose aspirin to reduce thrombosis risk
Education
Explain polycythemia vera, its chronic nature, and the potential for complications (thrombosis, bleeding).
Discuss the importance of regular monitoring and adherence to treatment plan.
Phlebotomy procedure (if applicable) and potential side effects.
Importance of recognizing and reporting new or worsening symptoms.
Follow-up
Schedule for frequent follow-up appointments in the initial phase, then gradually less frequent as controlled
Monitor blood counts closely to assess response to treatment
Consider referral to a hematologist (blood specialist) for complex cases or complications
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of polycythemia vera