Monoclonal Gammopathy Evaluation Note

Date: [Date of service] Encounter Type: [new consult / follow-up]; [in-person / telehealth] Referring Clinician: [Name, specialty] Reason for Referral: [Verbatim reason if available] Date of Abnormal Study: [Date] Data Sources: [internal labs / outside labs / outside records requested / outside records received]

Brief Summary

[One to two sentence summary of clinical question and visit purpose] (If insufficient information is available, state: "Summary pending outside records.")

Chief Complaint

[Chief complaint / reason for visit]

History of Present Illness

[Triggering abnormality narrative] (Describe why testing was obtained, what was detected, when detected, and whether this is new vs established/evolving.)

• Monoclonal Protein Data:
  • SPEP M-protein: [value g/dL] [migration region] [date] (If no discrete M-protein, note abnormal pattern.)
  • Serum immunofixation: [isotype] [date] (If not obtained, state "serum IFE not obtained"; do not infer isotype from SPEP alone.)
  • Quantitative immunoglobulins: IgG [value], IgA [value], IgM [value] [date]
  • Serum free light chains: kappa [value], lambda [value], ratio [value] [date] (Note if CKD may affect interpretation.)
  • Urine studies: [UA / UPCR / 24-hour urine protein / UPEP/UIFE] [dates] (If not obtained, note as needed.)

CRAB Symptom Screen:

• Hypercalcemia symptoms: [present / absent / unclear] (polyuria, polydipsia, constipation, confusion)
• Renal symptoms: [present / absent / unclear] (decreased output, foamy urine, edema; baseline kidney function: [known / unknown])
• Anemia symptoms: [present / absent / unclear] (fatigue, dyspnea, exercise intolerance)
• Bone symptoms: [present / absent / unclear] (focal bone pain, fracture history, height loss, back pain, radicular symptoms)

Additional Syndrome Screens: (Include when relevant to the abnormality or isotype)

• Recurrent infections/immunoparesis: [present / absent / unclear]
• Hyperviscosity symptoms: [present / absent / unclear] (headache, visual changes, epistaxis—especially IgM)
• Peripheral neuropathy: [present / absent / unclear] (sensory symptoms, gait instability, autonomic symptoms)
• Amyloidosis red flags: [present / absent / unclear] (heart failure symptoms, orthostasis, nephrotic edema, easy bruising, macroglossia, carpal tunnel, early satiety)
• B symptoms or lymphadenopathy: [present / absent / unclear] (especially IgM)

Pertinent Background: (Include only if relevant)

• Prior plasma cell disorder or lymphoma history: [details]
• Prior marrow or imaging results: [dates and key findings]
• Renal baseline: [baseline creatinine/eGFR if known]
• Fractures/osteoporosis history: [details]
• Relevant medications: [nephrotoxins, anticoagulants]
• Family history of plasma cell disorders: [details]

Physical Exam

(Targeted exam; if limited by telehealth, document limitations.)

• General appearance and performance status: [description]; ECOG [0 / 1 / 2 / 3 / 4]
• Volume status/edema: [findings]
• Lymph nodes: [palpable / not palpable]; Hepatosplenomegaly: [present / absent]
• Bone/spine tenderness: [present / absent]; Deformity: [present / absent]
• Neurologic (neuropathy-relevant): strength [findings], sensation [findings], gait [findings]
• Skin findings: [petechiae / purpura / ecchymoses / other] (Include if amyloidosis suspected.)
• Exam limitations: [none / telehealth / other]

Data Reviewed

Laboratory Results

• CBC: Hgb [value], MCV [value], platelets [value] [date]
• CMP: creatinine [value] (eGFR [value]), calcium [value], albumin [value], total protein [value] [date]
• Additional: LDH [value], beta-2 microglobulin [value] [date] (Include if myeloma suspected.)
• Interpretation of CRAB-relevant abnormalities: [attribution to plasma cell disorder: yes / no / unclear; alternative causes considered]

Monoclonal Protein Studies

• SPEP: M-spike [value g/dL] [date]; trend: [stable / increasing / decreasing / new]
• Serum IFE: [isotype] [date] (If not obtained, state needed.)
• Quantitative immunoglobulins: IgG [value], IgA [value], IgM [value] [date]
• Serum free light chains: kappa [value], lambda [value], ratio [value] [date]
• Urine studies: UA [result], UPCR [value], 24-hour protein [value], UPEP/UIFE [results] [dates] (If not obtained, state needed.)

Imaging

• [Date] [low-dose whole-body CT / skeletal survey / whole-body MRI / spine/pelvis MRI / FDG PET/CT] [anatomic coverage]: [key findings]; lytic lesions: [present / absent / indeterminate]

Bone Marrow

(Include if performed.)

• [Date] [Site]: Plasma cells [percentage]; Clonality: [kappa / lambda restriction]
• Flow cytometry: [summary]
• Cytogenetics/FISH: [standard risk / high-risk abnormalities / summary]
• Congo red: [positive / negative / not performed]

Assessment

Diagnostic Category

[non-IgM MGUS / IgM MGUS / light-chain MGUS / smoldering multiple myeloma / active multiple myeloma / solitary plasmacytoma / AL amyloidosis suspected / AL amyloidosis confirmed / MGRS suspected / MGRS confirmed / other]: [Brief supporting rationale] (If uncertain, use "concern for" or "possible" with workup pending.)

Myeloma-Defining Features (CRAB/SLiM)

• C (Hypercalcemia): [met / not met / unknown] — calcium [value] [date]; attributable to plasma cell disorder: [yes / no / unclear]
• R (Renal insufficiency): [met / not met / unknown] — creatinine [value] (baseline [value]) [date]; eGFR [value]; attributable: [yes / no / unclear]; alternative etiologies: [list]
• A (Anemia): [met / not met / unknown] — Hgb [value] [date]; attributable: [yes / no / unclear]; alternative causes: [iron deficiency / CKD / bleeding / other]
• B (Bone lesions): [met / not met / unknown] — [modality] [date]; lytic lesions: [present / absent / indeterminate]
• SLiM biomarkers: (Only include if data available.)
  • Bone marrow clonal plasma cells: [percentage] [date]
  • Involved/uninvolved FLC ratio: [ratio]; involved FLC: [value] [date]
  • MRI focal lesions: [number, size] [date]
• Missing data: [tests needed] (Include if any CRAB/SLiM criteria cannot be assessed.)

Risk Stratification

• MGUS: Isotype [IgG / non-IgG]; M-protein [value g/dL]; FLC ratio [normal / abnormal] — Risk tier: [low / low-intermediate / high-intermediate / high / cannot assign—data needed: specify]
• Smoldering myeloma (20/2/20): M-protein [value g/dL]; involved/uninvolved FLC ratio [value]; bone marrow plasma cells [percentage]; cytogenetic risk [standard / high-risk / unknown] — Risk tier: [low / intermediate / high / cannot assign—data needed: specify]
• Risk category implications for surveillance: [brief statement]

Plan

Recommended Workup

• Monoclonal protein studies: [SPEP / serum IFE / quantitative Ig / FLC] — Rationale: [brief]
• CRAB assessment: [CBC / CMP] — Rationale: [brief]
• Prognostic markers: [LDH / beta-2 microglobulin] — Rationale: [brief] (Include if myeloma suspected.)
• Urine characterization: [UA / UPCR / 24-hour urine with UPEP/UIFE] — Rationale: [brief]
• Amyloidosis workup: [NT-proBNP / BNP / troponin / urine protein quantification] — Rationale: [brief] (Include if amyloidosis suspected.)

(Do not repeat reliable recent studies; reference date reviewed.)

Imaging Recommendation

[low-dose whole-body CT / whole-body MRI / spine/pelvis MRI / FDG PET/CT / no additional imaging indicated]: [Rationale for modality choice or deferral]

Bone Marrow Evaluation

• Disposition: [indicated now / deferred / already performed]
• Rationale: [drivers for proceeding or deferring]
• If proceeding: Request plasma cell clonality, flow cytometry, cytogenetics/FISH, Congo red [if indicated]
• If already performed: [summary and whether repeat needed]

Surveillance Plan

• First reassessment: [timeframe]
• Ongoing interval: [frequency based on risk category]
• Tests each interval: [CBC, calcium, creatinine, SPEP, serum IFE, FLC; urine studies if indicated]
• Imaging reassessment: [timeframe and modality if applicable]

Escalation Triggers

• New or worsening focal bone pain or fracture
• Rising M-protein or rapidly changing FLC ratio
• New anemia, creatinine rise, or hypercalcemia
• Progressive proteinuria, edema, or cardiac symptoms suggesting amyloidosis
• Constitutional symptoms, lymphadenopathy, or hyperviscosity symptoms

Counseling

[Patient education provided]: (Document explanation of monoclonal protein significance, that precursor conditions are monitored rather than treated, surveillance rationale and limitations. If marrow or imaging recommended, document consent discussion. If not completed, note plan to address at next visit.)

Coordination

• Communication with referring clinician: [summary and method]
• Referrals: [nephrology / cardiology / neurology / none] — Indication: [reason]
• Outside records: [requested / received / pending] — [source and status]