Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint): Briefly describe the patient’s main reason for presentation, which can vary but may include:
Fatigue
Easy bruising or bleeding
Petechiae (tiny red spots on the skin)
Fever or chills
Bone pain
Shortness of breath
Frequent infections
History of Present Illness:
Onset and duration of symptoms
Severity of symptoms
Associated symptoms (weight loss, night sweats, loss of appetite)
Past medical history (previous diagnoses, significant surgeries, childhood illnesses)
Family history (cancer in blood relatives)
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate)
General examination (appearance of illness, pallor)
Lymph node examination: Look for enlarged lymph nodes (cervical, axillary, inguinal)
Skin examination: Check for petechiae or other rashes
Spleen examination: Assess for splenomegaly (enlarged spleen)
Laboratory Findings:
Complete blood count (CBC):
Low red blood cell (RBC) count (anemia)
Low white blood cell (WBC) count (leukopenia)
Low platelet count (thrombocytopenia)
Peripheral blood smear may show characteristic lymphoblasts
Bone marrow aspiration and biopsy: Definitive test for ALL, identifies the type of lymphoblasts.
Cytogenetic analysis: Analyzes chromosomal abnormalities in the leukemic cells.
Other tests: May include blood chemistry, lactate dehydrogenase (LDH), and testing for specific genetic mutations.
Imaging Studies:
Chest X-ray: May show signs of enlarged lymph nodes in the chest.
CT scan (optional): May be used to assess lymph node involvement and other organ enlargement.
Assessment:
Summarize the findings and diagnose acute lymphoblastic leukemia (ALL) based on clinical presentation, laboratory tests, and bone marrow examination.
Specify the subtype of ALL based on immunophenotyping (e.g., B-cell ALL, T-cell ALL).
Describe the risk stratification group based on age, cytogenetics, and other factors.
Consider the potential complications of ALL (infections, bleeding, organ infiltration).
Plan:
Induction Chemotherapy: This is the initial phase of treatment using a combination of chemotherapy drugs to achieve remission (reduction of leukemia cells).
Consolidation Therapy: Aims to eliminate remaining leukemia cells and prevent relapse.
Maintenance Therapy: Aims to further reduce the risk of relapse.
Supportive Care:
Management of infections due to compromised immune system
Blood product transfusions (red blood cells, platelets) as needed
Nutritional support
Specialty Consultations:
Pediatric hematology/oncology (for children)
Adult hematology/oncology (for adults)
Progress Notes:
Document daily assessments including vital signs, weight, presence of infections, and response to treatment.
Note any changes in blood counts and other laboratory results.
Update the plan as needed based on the patient’s response to treatment and development of complications.
Discharge Instructions (for patients in remission):
Follow-up appointments with a hematologist/oncologist to monitor for relapse
Importance of maintaining good hygiene to prevent infections
Education on potential side effects of treatment
Support groups and resources for patients with ALL
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment of Acute Lymphoblastic Leukemia.