Patient: [Patient Name]
Date: [Date of Encounter]
I. History of Present Illness:
Bleeding history (present or absent):
Type of bleeding (mucosal, easy bruising, menorrhagia)
Frequency and severity of bleeding episodes
Past surgical procedures and bleeding complications (if any)
Reason for this visit (routine follow-up, new or worsening bleeding)
II. Past Medical History:
Age at diagnosis of congenital dysfibrinogenemia
Family history of bleeding disorders (yes/no)
III. Social History:
Medications (anticoagulants, antiplatelet agents) (avoid if known diagnosis)
Occupational hazards for bleeding (activities, potential trauma)
Women: Menstrual history (heavy periods)
IV. Physical Exam:
Vital signs: (BP, HR, RR, Temp)
Signs of bleeding (e.g., petechiae, ecchymoses, mucous membrane bleeding)
Joint examination (signs of past hemarthrosis)
V. Laboratory Studies:
Complete blood count (CBC) (may show microcytic anemia if chronic bleeding)
Prothrombin time (PT) – usually prolonged in dysfibrinogenemia
Activated partial thromboplastin time (aPTT) – may be prolonged
Fibrinogen level: (low)
Fibrinogen activity assay (may be used to confirm diagnosis)
VI. Assessment:
Severity of congenital dysfibrinogenemia (based on bleeding symptoms and lab findings)
Risk of future bleeding complications
VII. Plan:
Prophylactic treatment (to prevent bleeding episodes):
Fibrinogen replacement therapy (type, dose, route of administration) – fresh frozen plasma (FFP) or fibrinogen concentrate
Use with caution due to risk of anaphylaxis (especially with plasma)
Consider tranexamic acid (antifibrinolytic medication)
Management of acute bleeding episodes:
Fibrinogen replacement therapy (consider urgency based on severity)
Local measures (pressure, topical hemostatic agents)
Blood product transfusion (may be necessary in severe cases)
Education:
Importance of avoiding medications that worsen bleeding (aspirin, NSAIDs)
Recognizing signs and symptoms of bleeding.
Bleeding precautions to minimize injuries and activities that increase bleeding risk.
Importance of carrying a medical alert card.
Referral (if indicated):
Hematologist for specialized care and management.
Genetic counseling (if considering family planning).
VIII. Notes:
Include any additional observations or concerns, such as patient’s understanding of the condition, response to treatment, and emotional well-being.
Mention the importance of ongoing monitoring and potential complications (anemia, iron deficiency).
IX. Resources:
Consider providing patient education materials on congenital dysfibrinogenemia from reputable sources (e.g., National Hemophilia Foundation, National Institutes of Health (NIH)).