NLN Patient Summit at the 25th World Congress of Lymphology Sept. 8-9, 2015 San Francisco Union Square Hotel San Francisco, CA Patient Clinic Guidelines To have your personal case history considered for the Patient Clinic on September 8, please follow the guidelines below: 1. Draft a written document detailing your medical history Include information and personal statistics such as: height, weight, your vocation (or if you are a full-time student or retired), hobbies you take part in on at least a semi-regular basis, type of exercise you do, if any, if you have children (if so, how many and what ages), and any additional information you think might impact your lymphedema. 2. Submit a photo (8x10 or 8x12), showing the affected limb(s)/area of the body and the non-affected (for comparison). 4. Your case study will be posted in the Patient Summit general session area, and can be viewed during the two day Summit. 5. There are numerous patients interested in presenting their case during the Patient Clinic, but we can only accept three (3). If you feel your case is unique, please be sure to explain this. Unique, in this case, would mean (for example) that there is no response to CDT, or there are additional medical problems interfering with treatment, or an especially challenging case with positive response to treatment but additional questions/concerns. In other words, your participation should benefit both you and others who will be attending the Patient Clinic to learn from your case and each other. Please note that the deadline for submission and consideration of case histories is: May 15, 2015. We look forward to receiving your application. If you have additional questions, please do not hesitate to contact Saskia RJ Thiadens, RN, at 1-415-908-3680 ext: 105 or [email protected] Best wishes, The 2015 NLN Patient Summit Committee National Lymphedema Network, Inc. | 225 Bush Street, Ste 357, San Francisco, CA 94104 415-908-3681 | Fax: 415-908-3813 | [email protected] | www.lymphnet.org NLN Patient Clinic 2015 Patient Name: Patient Case History Patient’s Name: ____________________________________________________________ 1. Female Male 2. Age: _______ 3. Profession: _____________________________________________________________ 4. If under 18, parents’ names: __________________________________________ 5. Type of lymphedema: 6. Affected limb(s): Upper Lower Right Left If “Other Area/s,” location? ________________________________________________ 7. Type of surgery, if secondary: ______________________________________________ Year this was performed: 19__________ or 200_______ 8. If cancer-related: Primary Secondary Related Condition Other area/s Sentinel lymph node only (SLN) How many negative? ____ SLN positive? Yes No Total number of lymph nodes removed: ________ How many positive? _____ Yes No Chemotherapy? Yes No 9. Radiation? Other treatment: ________________________________ 10. Infection(s)? Yes No Cause? _______________________________________ If yes, how many since the onset of your lymphedema? _____________________ How were the infections treated? ____________________________________________ _______________________________________________________________________ _______________________________________________________________________ 12. Complications? Yes No If yes, what? (Ex: post-op infection, seroma [fluid pocket], radiation skin changes, blood clot, non-healing wounds, or non-cancer-related problems) ______________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ NLN Patient Clinic 2015 Patient Name: MEDICAL HISTORY Please include a brief description of your medical history, in your own words, in the space provided below. Be sure to type clearly as this sheet will be posted next to your photo in the poster area. Please include information about other illnesses, like diabetes, heart conditions, skin disorders,, all other surgeries, etc. cont. on pg. 3 NLN Patient Clinic 2015 Patient Name: 13. Medications (presently taking)____________________________________________ ______________________________________________________________________ 14. Treatment methods used: Manual Lymphatic Drainage (MLD) Self-Bandaging Remedial Exercises– what type? _________________________________________ Pumps-specify type & how often pump is used: ______________________________ Garments-custom, standard or both? ______________________________________ Self-MLD Skin care Alternative Device/s - which? (i.e. Tribute, CircAid, Flexitouch etc.) ________________________ _____________________________________________________________________ Diet/Nutrition Education (lymphatic system) Alternative treatment:____________________________________________________ _____________________________________________________________________ 15. Briefly describe your treatment plan (including self-care) and the response to your treatment: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 16. Briefly describe any physical or psychological changes you have experienced as a result of your lymphedema (i.e. job loss, changes in sports activities, clothing changes, career changes, new life directions, depression): _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ NLN Patient Clinic 2015 Patient Name: _______________________________________________________________________ _______________________________________________________________________ cont. on pg. 4 NLN Patient Clinic 2015 Patient Name: 17. Who is supervising your treatment (i.e. lymphedema therapist or doctor)? __________________________________________________________________ 18. Are you involved in a lymphedema support group? 19. Are you in contact with others who have lymphedema/other parents of children with lymphedema? Yes No 20. List two or three key questions that you would like addressed. All questions from chosen case studies will be addressed during the Patient Clinic (specifically or generally). Yes No Question #1: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Question #2: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _____________________________________________________________________ Question #3: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 21. Please attach a photograph of yourself/your child and the affected limb/s (8”x10” or 8”x12”). This is mandatory in order for your case to appear as a poster in the Poster Session. In order for your case study to be considered, it is important to provide the expert Panel with your complete medical background. If your case is considered to be presented during the Patient Clinic, we are requesting before and after slides/images that will be shown during the Patient Clinic. 22. ADDITIONAL COMMENTS
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