Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for CLL, evaluation of symptoms or blood counts, treatment monitoring, or management of complications.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the following:
Presence of new or worsening symptoms that could suggest disease progression (e.g., fatigue, weight loss, recurrent infections, night sweats).
Any recent illnesses or infections.
Bleeding problems (easy bruising, frequent nosebleeds).
Adherence to medications and potential side effects.
Past Medical History:
Briefly summarize relevant past medical history, including:
Date of CLL diagnosis
Rai stage (prognostic staging system based on clinical features) or Binet stage (based on physical exam and laboratory findings)
Treatment history (watch and wait, chemotherapy, targeted therapies)
Presence of co-morbidities (e.g., autoimmune diseases, infections)
Social History:
Inquire about occupational exposures (e.g., certain chemicals) potentially linked to CLL.
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Physical Exam:
Assess for:
Lymphadenopathy (enlarged lymph nodes)
Splenomegaly (enlarged spleen)
Signs of infection (fever, pharyngitis)
Signs of bleeding (petechiae, ecchymoses)
Laboratory Tests (review recent results):
Complete blood count (CBC) with differential – assess for lymphocytosis (elevated white blood cell count), anemia, or thrombocytopenia (low platelet count).
Consider trends in lymphocyte count over time.
Consider additional tests as indicated:
LDH (lactate dehydrogenase) – elevated levels may suggest aggressive CLL.
Beta-2 microglobulin – another marker of disease activity.
Blood tests to assess for cytomegalovirus (CMV) or other infections.
Assessment (A):
Disease Stage:
Reassess the disease stage based on current clinical features and laboratory findings.
Lymphocyte Count and Trends:
Evaluate the white blood cell count, particularly lymphocyte count, and assess for significant changes or rapid rise.
Presence of Symptoms:
Correlate symptoms with disease progression or potential complications (e.g., infections, cytopenias).
Treatment Response (if applicable):
Evaluate response to current treatment based on symptom improvement, blood count changes, and any side effects.
Plan (P):
Treatment Plan:
Develop a treatment plan based on the stage of CLL, presence of symptoms, and individual needs. Options may include:
Watch and wait: Monitor the disease closely without immediate treatment for asymptomatic patients with early-stage CLL.
Chemotherapy: Combination chemotherapy regimens for patients with symptomatic or advanced CLL.
Targeted therapies: Newer medications targeting specific molecules involved in CLL growth (e.g., BTK inhibitors, venetoclax).
Supportive care: Management of infections, bleeding problems, and other complications.
Referral (if indicated):
Consider referral to a hematologist-oncologist for patients with complex CLL or requiring advanced treatment options.
Follow-up:
Schedule follow-up visits to monitor disease activity, blood counts, response to treatment, and manage complications.
Define the frequency of follow-up based on disease stage, treatment plan, and presence of symptoms.
Patient Education:
Educate the patient about CLL, its progression, and the rationale for the treatment plan.
Discuss the importance of monitoring for symptoms and signs of infection.
Provide information on potential side effects of treatment and the importance of reporting them.
Offer resources for support groups or educational materials on managing CLL.