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