Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Subjective:
Describe the patient’s current neurological symptoms suggestive of leptomeningeal involvement (e.g., headache, new-onset seizures, cognitive decline, gait abnormalities, numbness/weakness).
Inquire about the severity, duration, and any recent changes in these symptoms.
Ask about any vision problems or difficulty with balance.
Objective:
Vital signs: Include temperature, pulse, respiratory rate, blood pressure.
Neurological exam:
Assess mental status (orientation, memory, concentration).
Evaluate cranial nerve function (vision, hearing, facial movement).
Test motor and sensory function in all extremities.
Look for signs of meningeal irritation (nuchal rigidity, Kernig’s sign, Brudzinski’s sign).
Imaging results (if recent): Briefly describe findings from relevant imaging studies (MRI with gadolinium contrast) suggestive of leptomeningeal spread (e.g., meningeal enhancement, hydrocephalus).
Laboratory results (if recent): Mention relevant lab findings, like CSF analysis (elevated opening pressure, increased white blood cell count, cytology positive for malignant cells).
Assessment:
Diagnosis: State the suspected or confirmed diagnosis of leptomeningeal metastasis based on clinical presentation and investigations.
Primary malignancy: Identify the known or suspected primary tumor site.
Plan:
Treatment:
Outline the current treatment plan for leptomeningeal metastasis, which may involve:
Intrathecal chemotherapy delivered via lumbar puncture.
Systemic chemotherapy if appropriate for the primary tumor.
Corticosteroids to reduce inflammation.
Supportive care for symptom management (pain control, anti-seizure medications).
Imaging and CSF follow-up:
Specify the schedule for repeat MRI scans and CSF analysis to monitor response to treatment.
Palliative care consultation:
Consider referral to palliative care for symptom management and comprehensive support.
Prognosis: Discuss the prognosis with the patient and family, acknowledging the serious nature of leptomeningeal metastasis.