Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
New diagnosis of MDS OR follow-up for established MDS
(Specify) Symptoms of MDS can be vague and depend on the severity of cytopenias (low blood cell counts). Common complaints include:
Fatigue (due to anemia)
Increased susceptibility to infections (due to neutropenia)
Easy bruising or bleeding (due to thrombocytopenia)
Shortness of breath (anemia or lung involvement)
Bone pain (less common)
History of Present Illness:
Onset, duration, and severity of symptoms.
For established MDS:
Date of diagnosis and subtype (based on WHO classification system).
Prior treatment history (chemotherapy, supportive care).
Response to previous treatments (improvement or worsening of cytopenias, disease progression).
Any new or worsening symptoms.
History of blood transfusions.
Past Medical History:
Underlying medical conditions (e.g., prior chemotherapy or radiation for other cancers).
History of bone marrow disorders or cytopenias.
History of exposure to benzene or other toxins linked to MDS.
Family History:
Family history of blood cancers (not a strong risk factor for MDS).
Medications:
List all current medications, including:
Chemotherapy or other disease-modifying therapies used to treat MDS.
Medications to manage cytopenias (e.g., erythropoietin for anemia, growth factors for neutropenia, platelet transfusions).
Supportive medications (e.g., antibiotics for infections, pain medications).
Social History:
Smoking history (smoking may increase risk of MDS).
Occupational exposures to potential toxins (e.g., benzene).
Physical Exam:
General examination: Assess for signs of anemia (pale skin, fatigue), bleeding (petechiae, ecchymoses), or infections (fever, lymphadenopathy).
Laboratory Tests:
Complete blood count (CBC): Essential for diagnosing and monitoring MDS. Low red blood cell count (anemia), white blood cell count (neutropenia), or platelet count (thrombocytopenia) are characteristic findings.
Peripheral blood smear: Microscopic examination of blood cells to assess for abnormal morphology suggestive of MDS.
Bone marrow aspiration and biopsy: Definitive diagnostic test for MDS. Examines the cellular composition of the bone marrow for abnormal features.
Cytogenetic testing: Analyzes chromosome abnormalities in bone marrow cells, which can influence prognosis and treatment decisions.
Imaging Studies:
Imaging studies are not routinely used for diagnosis of MDS. However, X-rays or CT scans may be done to rule out other conditions or assess for complications (e.g., bone infections).
Assessment:
Myelodysplastic syndrome (MDS): Based on characteristic findings on peripheral blood smear and bone marrow examination. The specific subtype is classified based on the WHO classification system.
Cytopenias: Specify the presence and severity of anemia, neutropenia, and thrombocytopenia based on CBC results.
Prognosis: Estimated based on factors like age, cytopenias, bone marrow blast percentage, and cytogenetic abnormalities.
Differential Diagnoses:
Consider other conditions that can cause cytopenias:
Aplastic anemia
Vitamin deficiencies (B12, folate)
Hypersplenism
Myeloproliferative neoplasms (MPN) in early stages (may overlap with MDS)
Plan:
Treatment:
The goal of treatment is to manage cytopenias, improve symptoms, and potentially delay progression to acute myeloid leukemia (AML). Treatment options depend on various factors like age, overall health, disease subtype, and cytogenetic abnormalities.
Supportive care: Blood transfusions, antibiotics for infections, growth factors to stimulate blood cell production.
Hypomethylating agents (HMAs): Medications that can improve blood counts and delay progression to AML.
Chemotherapy: Used in some cases, particularly for higher-risk MDS.
Stem cell transplantation (SCT): Potentially curative for younger patients with a suitable donor.