Date:
Patient:
MRN:
Attending Physician:
Reason for Visit:
Follow-up for essential thrombocythecyhemia (ET)
Evaluation of laboratory results
Management of treatment side effects
Assessment for thrombotic events
History of Present Illness:
Briefly summarize the patient’s ET diagnosis, including:
Date of diagnosis
Presenting symptoms (if any) – some patients with ET may not have symptoms.
Current platelet count
Past Medical History:
Include any relevant past medical conditions, such as:
History of thrombosis (deep vein thrombosis, pulmonary embolism)
Hypertension
Hyperlipidemia
Cardiovascular disease
History of bleeding
Social History:
Tobacco use (current and past)
Alcohol use
Family History:
History of myeloproliferative neoplasms (MPN) in first-degree relatives
Medications:
List all current medications, including:
Cytoreductive therapy (hydroxyurea, interferon)
Antiplatelet agents (aspirin)
Medications for comorbidities (blood pressure medications, cholesterol medications)
Physical Exam:
General: Appearance of health, signs of bleeding (petechiae, ecchymosis)
Vital Signs: Temperature, pulse, blood pressure
Labs:
List recent complete blood count (CBC) with differential, including platelet count.
Consider mentioning other blood tests as relevant, such as JAK2 mutation testing.
Imaging:
Mention any recent imaging studies performed to assess for complications of ET or to rule out other diagnoses.
Assessment:
Summarize the patient’s current clinical status:
Current platelet count and trend
Presence of any symptoms suggestive of thrombosis or bleeding
Response to treatment (if applicable)
Risk of thrombosis based on established criteria
Plan:
Outline the next steps in the patient’s care:
Treatment plan adjustments based on platelet count, risk factors, and patient preference (continue current therapy, initiate cytoreductive therapy, adjust antiplatelet therapy)
Follow-up schedule for laboratory tests and clinic visits
Management of treatment side effects
Education on signs and symptoms of thrombosis and bleeding
Consideration for genetic counseling if JAK2 mutation positive
Prognosis:
Briefly discuss the patient’s long-term prognosis, considering factors like age, presence of comorbidities, and response to treatment.
Notes:
Include any additional relevant information not covered above.
Disclaimer: This is a template and should be adapted to the specific needs of each patient.