Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint:
Document the patient’s main concerns related to their suspected irAE. Examples include:
Skin rash, itching
Diarrhea, abdominal pain
Fatigue, shortness of breath
Muscle weakness, numbness
现病史 (xiàn bìng shǐ) History of Present Illness:
Onset and duration of symptoms
Progression or worsening of symptoms
Impact on daily activities (work, hobbies)
Any recent changes in medications (including over-the-counter)
既往史 (jì wàng shǐ) Past Medical History:
Underlying malignancy and current treatment status (type of ICI, dose, number of cycles)
History of autoimmune diseases (increases risk of irAEs)
Other relevant medical conditions
药物过敏史 (yào wù guò mìn shǐ) Medication Allergies:
Allergies to any medications, including prior reactions to ICIs
家族史 (jiā zú shǐ) Family History:
Family history of autoimmune diseases (uncommon)
社会史 (shè huì shǐ) Social History:
Current medications and supplements
Smoking history (may worsen some irAEs)
查体 (chá tǐ) Physical Examination:
Vital signs (may be normal or show signs of infection)
General examination:
Skin: rash, dryness, itching
Mucous membranes: dryness, inflammation
Cardiopulmonary exam (if respiratory symptoms present)
Abdominal exam (if gastrointestinal symptoms present)
Neurological exam (if neurological symptoms present)
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Complete blood count (CBC) – assess for infection or inflammation
Electrolytes – to assess for imbalances (e.g., diarrhea)
Liver function tests (LFTs) – to assess for liver involvement
Thyroid function tests (TFTs) – to assess for thyroid dysfunction
Inflammatory markers (ESR, CRP) – may be elevated in some irAEs
Autoimmune markers (depending on suspected irAE)
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Chest X-ray (if respiratory symptoms present)
CT scan (chest, abdomen/pelvis) – may be needed depending on the suspected irAE
诊断 (zhěn duàn) Diagnosis:
Suspected immune-related adverse event (irAE) secondary to ICI therapy.
Specify the suspected organ system involved (e.g., ICI-related pneumonitis, ICI-related colitis).
鉴别诊断 (jiàn bié zhěn duàn) Differential Diagnosis:
Consider alternative causes for the patient’s symptoms based on the clinical presentation.
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Depends on the type and severity of the irAE. May include:
Withholding or reducing the dose of ICI therapy (in consultation with oncologist)
Corticosteroids (to suppress the immune system)
Other immunosuppressive medications (depending on the irAE)
Supportive care (managing symptoms like diarrhea or pain)
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of the irAE, response to treatment, and the underlying malignancy.
Early diagnosis and treatment of irAEs can improve outcomes and allow continuation of ICI therapy.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of reporting any new or worsening symptoms promptly.
Importance of medication adherence for managing the irAE and underlying malignancy (if applicable).
Explanation of potential side effects of immunosuppressive medications.
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for the next appointment depends on the severity of the irAE and response to treatment.
Close monitoring is crucial to assess response to treatment and potential complications.
Additional Notes:
Document communication with the patient’s oncologist regarding potential adjustments to ICI therapy.
Consider referral to other specialists (e.g., dermatologist, gastroenterologist) depending on the specific irAE.