Date:
Patient:
MRN:
Clincian: (Hematologist, Oncologist)
Reason for Visit:
Follow-up for hairy cell leukemia (HCL)
Evaluation of symptoms (fatigue, frequent infections, bleeding)
Review of laboratory and imaging results
Discussion of treatment plan and potential complications
History of Present Illness:
Briefly describe the patient’s current status:
Duration of symptoms (fatigue, weakness, easy bruising or bleeding, recurrent infections)
Severity and impact of symptoms on daily activities
Response to previous treatment approaches (splenectomy, chemotherapy)
Past Medical History:
Underlying medical conditions (significant for treatment considerations)
Social History:
Not typically relevant unless affecting overall health or adherence to treatment.
Physical Exam:
General: Assess for pallor (anemia), easy bruising, and signs of infection.
Splenomegaly (enlarged spleen) is a common finding in HCL.
Lymphadenopathy (enlarged lymph nodes) may be present but is less common.
Labs:
Complete blood count (CBC): May show pancytopenia (low red blood cells, white blood cells, and platelets).
Consider mentioning other labs ordered as needed (blood smears to identify characteristic hairy cells, bone marrow biopsy for definitive diagnosis).
Imaging:
Abdominal ultrasound: Can assess spleen size and detect other potential abnormalities.
Imaging of the chest, abdomen, and pelvis (CT scan or PET scan) may be used for staging purposes in some cases.
Assessment:
Summarize the diagnosis and disease stage:
Confirmation of HCL diagnosis based on clinical presentation, laboratory findings (characteristic blood smear and/or bone marrow biopsy), and imaging results (splenomegaly).
Stage of HCL based on the extent of disease involvement (spleen, bone marrow, lymph nodes).
Plan:
Outline the treatment plan based on the assessment:
Observation: May be considered for asymptomatic patients with minimal disease burden.
Splenectomy: Historically used as first-line therapy, but now often combined with other modalities.
Chemotherapy: Purine nucleoside analogues (cladribine) are the mainstay of treatment for HCL.
Consider mentioning other treatment options used in specific cases (interferon, monoclonal antibodies).
Supportive care: Management of cytopenias (anemia, neutropenia) with blood transfusions and growth factors may be necessary.
Prophylactic antibiotics to prevent infections, especially in patients with neutropenia.
Prognosis:
Briefly discuss the prognosis. HCL is a chronic malignancy but has a relatively good prognosis with treatment. Early diagnosis and treatment can lead to long-term remission for many patients.
Emphasize the importance of ongoing monitoring with regular lab tests and follow-up appointments to assess treatment response and detect potential complications.
Education:
Document any education provided to the patient regarding:
The nature of HCL, its symptoms, and potential complications
The details of the planned treatment plan and potential side effects
The importance of regular follow-up appointments and monitoring for treatment response
Strategies to manage symptoms like fatigue and infection risk
The availability of support groups and resources for patients with HCL
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about treatment side effects, long-term prognosis, or the impact of HCL on daily activities.
Consider the emotional well-being of the patient and offer support or referral for mental health services if needed.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a hematologist or oncologist for diagnosis, treatment recommendations, and prognosis.