Date:
Patient:
MRN:
Clinician: (Hematologist, Internist)
Reason for Visit:
Follow-up for Factor V Leiden mutation
Evaluation for risk of thrombosis (blood clot formation)
Management of risk factors for thrombosis
Discussion of anticoagulation prophylaxis (preventive medication)
History of Present Illness:
Briefly describe the reason for initial testing that identified the Factor V Leiden mutation:
Personal or family history of venous thromboembolism (VTE) (deep vein thrombosis (DVT), pulmonary embolism (PE))
Unexplained pregnancy loss (may be considered in some cases)
Thrombosis prophylaxis during hospitalization or surgery
Past Medical History:
Include any relevant past medical conditions that increase thrombosis risk:
Previous VTE
Surgery or hospitalization (increased risk in the postoperative period)
Immobilization (e.g., cast)
Active cancer
Chronic inflammatory conditions
Hormonal therapy use (birth control pills, hormone replacement therapy)
Family History:
Presence of VTE or Factor V Leiden mutation in first-degree relatives
Social History:
Smoking history (current and past) – significant risk factor for thrombosis
Prolonged sitting or travel (economy class syndrome)
Labs:
Confirmation of Factor V Leiden mutation (genetic testing results)
Consider mentioning other labs as relevant, such as:
Complete blood count (CBC)
Prothrombin time (PT) and activated partial thromboplastin time (aPTT) – may be normal in Factor V Leiden carriers without thrombosis
Imaging:
Imaging studies are not routinely performed for Factor V Leiden mutation itself, but may be used to diagnose VTE if suspected.
Assessment:
Confirm the presence of Factor V Leiden mutation.
Assess the individual’s overall risk of thrombosis based on:
Presence of additional risk factors
Personal or family history of VTE
Discuss the bleeding risk (although generally low, certain situations may increase it).
Plan:
Outline the plan based on the patient’s individual risk profile:
For patients with low thrombosis risk and no history of VTE:
Lifestyle modifications to reduce risk (smoking cessation, weight management, increased physical activity)
Consideration of prophylactic measures during high-risk situations (e.g., prolonged immobilization)
For patients with moderate or high thrombosis risk or history of VTE:
Discuss the potential benefits and risks of anticoagulation prophylaxis with low-dose aspirin or warfarin (newer anticoagulants may be considered in specific cases).
Regular monitoring of anticoagulation therapy if initiated (applicable for warfarin).
Genetic counseling may be recommended to discuss the implications for family members.
Prognosis:
Briefly discuss the prognosis. Factor V Leiden mutation itself does not cause symptoms, but it increases the lifetime risk of VTE. With appropriate risk stratification and management, the risk of thrombosis can be significantly reduced.
Education:
Document any education provided to the patient regarding:
The nature of Factor V Leiden mutation and its association with thrombosis risk
Importance of lifestyle modifications to reduce risk
Benefits and risks of anticoagulation prophylaxis (if discussed)
Warning signs and symptoms of VTE
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the information and any concerns they may have.
Consider mentioning the importance of ongoing monitoring and potential need to adjust management over time.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a healthcare professional for diagnosis and treatment recommendations.