Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint: Briefly state the patient’s main reason for this visit. Does it relate to hereditary hemochromatosis (HH) symptoms (fatigue, joint pain, etc.) or follow-up for iron overload management?
History of Present Illness:
Date of HH diagnosis (if known)
Current symptoms related to HH (if any)
Frequency and severity of symptoms
Any recent changes in symptoms or overall health
Past Medical History:
Comorbid conditions (e.g., diabetes, arthritis)
Surgeries or hospitalizations
Medications (prescription and over-the-counter)
Allergies
Family History:
History of HH in first-degree relatives
Other relevant medical conditions in family members
Social History:
Alcohol intake
Diet (iron-rich foods, supplements)
Blood donation history
Physical Examination:
General appearance (fatigued, cachectic)
Skin findings (bronze pigmentation)
Hepatomegaly (enlarged liver)
Splenomegaly (enlarged spleen)
Joint tenderness
Laboratory Tests:
Serum ferritin level
Transferrin saturation
Liver function tests (LFTs)
Complete blood count (CBC)
Imaging Studies:
Liver MRI (if indicated)
Diagnosis:
Confirmed hereditary hemochromatosis
Suspected hereditary hemochromatosis (if workup ongoing)
Treatment Plan:
Phlebotomy schedule (frequency, volume)
Iron chelation therapy (if needed)
Dietary modifications (iron restriction)
Monitoring plan (ferritin, LFTs)
Genetic counseling (if appropriate)
Prognosis:
Discuss the long-term outlook with treatment
Importance of adherence to therapy and follow-up
Patient Education:
Explain HH and iron overload
Importance of following the treatment plan
Dietary recommendations
Signs and symptoms to watch for
Importance of regular follow-up