Thank you for your referral of John, whom I reviewed for suspected Multiple Myeloma. The patient presented with fatigue, bone pain, and recurrent infections, prompting this review. The patient's overall well-being has been significantly impacted by these symptoms.
On examination, no lymphadenopathy or hepatosplenomegaly was noted. The patient was alert and oriented.
**Past Medical History:**
- Hypertension
- Osteoporosis
- Recurrent chest infections
**Medications:**
- Amlodipine 5mg daily
- Alendronic acid 70mg weekly
- Co-amoxiclav 625mg twice daily (for current infection)
**Investigations:**
**SA Path 1 November 2024:**
Hb 105 g/L
WCC 4.5 x10^9/L
LC 1.2 x10^9/L
PLT 250 x10^9/L
Biochem NAD
Igs all Abnormal
PP 0
SFLC Abnormal
EBV and CMV not detected
Hep B, Hep C and HIV not detected
**Clinpath 1 November 2024:**
Hb 105 g/L
MCV 85 fL
WCC 4.5 x10^9/L
LC 1.2 x10^9/L
PLT 250 x10^9/L
Biochem NAD
Igs all Abnormal
B12 Normal
Iron studies Normal
Urine culture Negative
ESR 60 mm/hr
CRP 20 mg/L
HbA1c 5.5%
TFTs Normal
Lipid profile Normal
PSA 0.8 ng/mL
**Clinpath 1 November 2024:**
Hb 105 g/L
WCC 4.5 x10^9/L
LC 1.2 x10^9/L
PLT 250 x10^9/L
Biochem NAD
**Impression:**
- Suspected Multiple Myeloma, currently under investigation.
- Hypertension, Osteoporosis, Recurrent chest infections.
The patient's condition is concerning due to the elevated serum free light chains and abnormal immunoglobulin levels. The blood counts are stable, but the ESR is elevated, indicating ongoing inflammation. Imaging results are pending. The risks of progression include worsening bone disease, renal impairment, and increased susceptibility to infections.
**Suggested Management Plan:**
- Repeat serum free light chains, protein electrophoresis, complete blood picture, renal function, electrolytes, liver function testing, IgG, IgM, IgA in 3 months.
- Annual physical reviews, including assessment for specific clinical signs such as lymphadenopathy, hepatosplenomegaly, and evaluation for infections including specific immune markers.
- Counselling points for annual reviews, such as staying up to date with non-live vaccinations and age-appropriate malignancy screens.
**An earlier review should be arranged if:**
- Constitutional symptoms, new lymphadenopathy or hepatosplenomegaly, CRAB criteria, or rapidly rising K/L ratio.
- Hypogammaglobulinaemia with frequent infections and potential eligibility for specific treatments.
The patient will be followed up in the haematology clinic in 3 months. The referring clinician should be aware of the potential for disease progression and should contact the haematology team immediately if any concerning symptoms arise.
Thank you for your referral of [patient's first name], whom I reviewed for [condition, symptoms or results requiring further investigation]. [Summarise the patient's current status, including reasons for the review, any new medical illnesses, changes in medication, or resolution of previous conditions, and overall well-being.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph of full sentences.)
On examination, [findings of lymphadenopathy or hepatosplenomegaly] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.) [Other relevant physical examination findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single sentence.)
**Past Medical History:**
- [Past medical diagnoses and conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list. If the bulleted list exceeds more than 5 lines, format into two columns.)
**Medications:**
- [Current medications] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Include dosage and frequency if available. Write as a bulleted list. If the bulleted list exceeds more than 5 lines, format into two columns.)
**Investigations:**
[Copy all investigations manually put into context notes by the doctor, do not summarise]
(Only include the findings below if explicitly mentioned in transcript, context or clinical note, else omit entirely. Present in the following format:)
**SA Path [Date]:**
Hb [Hb value]
WCC [WCC value]
LC [Lymphocyte count value]
PLT [Platelet value]
Biochem [Biochem result or NAD]
Igs all [Immunoglobulin result or NAD]
PP 0
SFLC [SFLC ratio result: normal/abnormal]
EBV and CMV [EBV/CMV result or not detected]
Hep B, Hep C and HIV [hepatitis/HIV result or not detected]
**Clinpath [Date]:**
Hb [Hb value]
MCV [MCV value]
WCC [WCC value]
LC [Lymphocyte count value]
PLT [Platelet value]
Biochem [Biochem result or NAD]
Igs all [Immunoglobulin result or NAD]
B12 [B12 result or normal]
Iron studies [Iron studies result or normal]
[Urine culture or other microbiology result]
ESR [ESR value]
CRP [CRP value]
HbA1c [HbA1c value]
TFTs [TFTs result or NAD]
Lipid profile [Lipid profile result or summary]
PSA [PSA value]
**Clinpath [Date]:**
Hb [Hb value]
WCC [WCC value]
LC [Lymphocyte count value]
PLT [Platelet value]
Biochem [Biochem result or NAD]
**Impression:**
- [Primary diagnosis and its current status, including stability of relevant markers] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single bullet point.)
- [Secondary diagnoses or resolved conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single bullet point.)
[Detailed narrative assessment of the patient’s condition, discussing the stability of the primary diagnosis, blood counts, organ function (renal, calcium, haemoglobin), imaging results, and any discussed risks of progression.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph of full sentences.)
**Suggested Management Plan:**
- [Recommendations for ongoing assessments including frequency and specific tests (e.g., serum free light chains, protein electrophoresis, complete blood picture, renal function, electrolytes, liver function testing, IgG, IgM, IgA) and due dates for next testing] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single bullet point.)
- [Recommendations for annual physical reviews, including assessment for specific clinical signs such as lymphadenopathy, hepatosplenomegaly, and evaluation for infections including specific immune markers] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single bullet point.)
- [Counselling points for annual reviews, such as staying up to date with non-live vaccinations and age-appropriate malignancy screens] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single bullet point.)
**An earlier review should be arranged if:**
- [Concerning features or symptoms such as constitutional symptoms, new lymphadenopathy or hepatosplenomegaly, CRAB criteria, or rapidly rising K/L ratio] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single bullet point.)
- [Criteria for discussing with the referring clinician, such as hypogammaglobulinaemia with frequent infections and potential eligibility for specific treatments] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single bullet point.)
[State the current follow-up plan with the specialist and provide instructions for the referring clinician regarding interim concerns.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph of full sentences.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)