Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Fatigue / Weakness / Weight loss / Night sweats / Easy bruising or bleeding / (Specify any other concerning symptoms)
Follow-up for mantle cell lymphoma (MCL)
History of Present Illness:
For new patients, describe the onset, duration, and severity of symptoms suggestive of MCL.
For follow-up visits, inquire about any new or worsening symptoms since the last encounter.
Past Medical History:
Underlying medical conditions (e.g., autoimmune diseases, chronic infections).
Previous treatments for MCL (chemotherapy, radiation therapy, stem cell transplant).
History of other malignancies.
Medications:
List all current medications, including any medications for MCL treatment or supportive care.
Social History:
Tobacco use (more common in MCL patients).
Family History:
Inquire about a family history of lymphomas or other cancers.
Physical Exam:
Vital signs: Assess for fever, tachycardia (rapid heart rate).
General observation: Look for signs of paleness, jaundice (yellowing of skin), lymphadenopathy (swollen lymph nodes), and hepatosplenomegaly (enlarged liver and spleen).
Ear, nose, and throat (ENT) exam: Palpate for lymphadenopathy in the neck.
Laboratory Tests:
Complete blood count (CBC): May reveal anemia, lymphocytosis (increased lymphocytes), and thrombocytopenia (low platelets).
Lactate dehydrogenase (LDH): Often elevated in MCL.
Peripheral blood flow cytometry: Confirms the diagnosis of MCL by identifying characteristic immunophenotype of the lymphoma cells.
Bone marrow biopsy: May be performed to assess for bone marrow involvement by MCL.
Imaging studies (CT or PET scan): Evaluates the extent of disease (lymph node involvement, organ involvement).
Assessment:
Mantle cell lymphoma diagnosis: State whether MCL is confirmed, suspected, or ruled out based on clinical presentation, laboratory findings, and flow cytometry results.
Stage of disease (if diagnosed): If MCL is confirmed, stage the disease using the International Mantle Cell Lymphoma Working Group (IMCLWG) criteria to determine the extent of spread.
Performance status: Assess the patient’s overall functional status using a scoring system (e.g., ECOG performance status).
Risk stratification (if diagnosed): Classify the patient’s risk group based on factors like age, performance status, and Ki-67 proliferation index, which helps guide treatment decisions.
Plan:
Definitive diagnosis (if not already confirmed): Discuss the need for a bone marrow biopsy to confirm the diagnosis if not already done.
Treatment plan (if newly diagnosed or relapsed/refractory):
Treatment for MCL typically involves a combination of chemotherapy with novel agents like ibrutinib.
Discuss potential benefits and risks of various treatment options based on the stage, risk stratification, and patient’s preferences.
Consideration of stem cell transplant may be discussed for eligible patients.
Treatment monitoring (if on treatment): Schedule regular follow-up visits to monitor response to treatment, assess for side effects, and perform repeat blood tests and imaging studies.
Supportive care: Provide supportive measures to manage symptoms (e.g., fatigue, anemia) and improve quality of life.
Clinical trials: Patients with relapsed/refractory MCL or those seeking potentially curative options may be eligible for participation in clinical trials.
Education:
Educate the patient about MCL, symptoms, diagnosis, treatment options, and potential side effects.
Discuss the importance of adherence to treatment plan and regular follow-up visits.
Provide resources for support groups or patient advocacy organizations for MCL.
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. Mantle cell lymphoma is an aggressive form of non-Hodgkin lymphoma. Treatment decisions should be made in consultation with a hematologist/oncologist specializing in lymphoma treatment. It is recommended to consult with relevant medical resources and MCL treatment guidelines for comprehensive care planning.