Dear Dr. Smith,
I am writing to update you on the recent consultation with, John Doe, who attended our Haematology clinic on 1 November 2024.
Reason for Referral:
Patient referred due to persistent fatigue, unexplained bruising, and abnormal blood test results.
Diagnosis:
Suspected Chronic Lymphocytic Leukaemia (CLL).
Past Medical History:
1. Hypertension, managed with Lisinopril 10mg daily.
2. Previous appendectomy in 2010.
Medications:
Lisinopril 10mg daily, and over-the-counter Vitamin D supplements.
Allergies:
No known drug allergies.
Social History:
Non-smoker, occasional alcohol consumption. Works as an accountant. Lives with his wife.
Examination Findings:
Patient appeared pale but was alert and oriented. Mild splenomegaly noted on palpation. No lymphadenopathy.
Investigations:
* Full Blood Count (FBC): Elevated white blood cell count (WBC) with lymphocytosis.
* Peripheral Blood Smear: Shows atypical lymphocytes.
* Flow Cytometry: Confirmatory for CLL.
Consultation:
During the consultation, we discussed the preliminary findings of the blood tests and the possibility of CLL. I explained the nature of the disease, the need for further investigations, and the potential treatment options. The patient expressed concerns about his prognosis and the impact on his daily life. We discussed the importance of regular monitoring and the potential need for treatment in the future. We also addressed his questions about the side effects of potential therapies and the importance of lifestyle modifications.
Management Plan:
1. Repeat FBC and blood film in 3 months.
2. Referral to a haematology specialist nurse for education and support.
3. Discussed the option of watchful waiting.
4. Advised the patient to maintain a healthy lifestyle, including a balanced diet and regular exercise.
Follow up appointment
**FTF appointment in 3 months**
GP to action:
* Continue monitoring blood counts.
* Provide support and reassurance to the patient.
* Inform the patient of the results of the blood tests.
We will continue to monitor John's progress and keep you updated on any significant changes. Please do not hesitate to contact us if you require any further information.
Yours sincerely,
Dr. Thomas Kelly
Consultant Haematologist
01234 567890
