Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint: Describe the patient’s current symptoms related to the suspected hypersensitivity reaction. This may include:
Skin rash (describe location, severity, itching)
Flushing
Chills
Fever
Shortness of breath
Wheezing
Chest tightness
Nausea
Vomiting
Diarrhea
Hypotension (if documented)
Angioedema (swelling of the face, lips, tongue, or throat)
现病史 (xiàn bìng shǐ) History of Present Illness:
Onset and duration of symptoms in relation to chemotherapy administration (during or after)
Severity of symptoms (progressive, worsening)
Any previous episodes of similar reactions with chemotherapy or other medications
Management of symptoms (e.g., medications administered)
既往史 (jì wàng shǐ) Past Medical History:
History of allergies (medications, food, environmental)
Atopy (personal or family history of eczema, asthma, allergic rhinitis)
Prior chemotherapy history (specific drugs, reactions)
Other relevant medical conditions (e.g., asthma, autoimmune diseases)
药物过敏史 (yào wù guò mín shǐ) Medication Allergy History:
List all current and recent medications, including chemotherapy drugs.
Note any known allergies to medications.
家族史 (jiā zú shǐ) Family History:
Family history of allergies or atopy
查体 (chá tǐ) Physical Examination:
Vital signs (temperature, blood pressure, oxygen saturation)
General appearance (respiratory distress, signs of rash or angioedema)
Skin exam (describe rash characteristics – location, type, color)
Lung exam (wheezing, crackles)
Other relevant findings (e.g., lymph node swelling)
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Complete blood count (CBC) – may show eosinophilia (increased white blood cells) in some cases
Basic metabolic panel – may show electrolyte imbalances
Consideration of specific allergy testing (limited role in chemotherapy reactions)
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Imaging studies are not typically needed for diagnosis unless respiratory symptoms are severe and chest X-ray is warranted to rule out other causes.
诊断 (zhěn duàn) Diagnosis:
Suspected hypersensitivity reaction to chemotherapy (specify suspected agent if known)
Severity of reaction (mild, moderate, severe) – based on clinical presentation
鉴别诊断 (jiàn bié zhěn duàn) Differential Diagnosis:
Consider other causes of skin rash, fever, or respiratory symptoms based on clinical presentation (e.g., infection, tumor flare)
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Immediate:
Discontinuation of suspected chemotherapeutic agent
Supportive care for symptoms (e.g., antihistamines, corticosteroids, bronchodilators)
Consider epinephrine for severe reactions (anaphylaxis)
Long-term:
Identification of alternative chemotherapeutic agents (if needed)
Premedication with corticosteroids or antihistamines for subsequent chemotherapy cycles (consideration based on severity)
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of the reaction, ability to identify the culprit agent, and potential for alternative chemotherapy options.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of reporting any future symptoms suggestive of hypersensitivity reaction
Avoidance of the identified chemotherapeutic agent
Importance of medication adherence for prescribed supportive medications
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for the next appointment depends on the severity of the reaction and need for further evaluation or monitoring.
Close communication is essential to ensure prompt identification and management of any future reactions.