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CHEMOTHERAPY CLINIC FOLLOWUP NOTE

 

DATE OF VISIT: XX/XX/XXXX

 

SUBJECTIVE:  The patient returns to clinic today for evaluation. His last phlebotomy for his secondary erythrocytosis was 1 year ago.  He states he is feeling fine.  He denies any headaches, no changes in thinking or other problems.  No fevers, chills or night sweats.

 

OBJECTIVE:  Well-appearing man with ruddy facies.

 

Laboratory data from today:  Chemistries are notable for a glucose of 133, total protein 8.2, otherwise normal. CBC:  White count 7.4, hemoglobin 19.1, hematocrit 56.2, platelet count 211.  Differential:  68.2 neutrophils and 22.2 lymphocytes. 

 

ASSESSMENT:  Patient is a XX-year-old gentleman with secondary polycythemia who is doing quite well. Today his hematocrit is above 55%.  Will proceed with phlebotomy.

 

PLAN:

1.  Phlebotomy 500 cc today.

2.  Return to clinic in four months with CBC, CMP and schedule phlebotomy.

Patient Name
Patient Medical Record Number
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