Patient: [Patient Name]
Date: [Date of Encounter]
I. Chief Complaint:
Respiratory symptoms (cough, wheezing, sputum production, shortness of breath)
Gastrointestinal symptoms (diarrhea, constipation, abdominal pain, bloating)
Fatigue
Weight loss
II. History of Present Illness:
Exacerbation of respiratory symptoms (increased cough, sputum production, shortness of breath) – if applicable
Changes in bowel habits
Changes in weight or appetite
Adherence to medications and airway clearance techniques
III. Past Medical History:
Age at diagnosis of cystic fibrosis (CF)
CFTR genotype (if known)
History of CF pulmonary exacerbations
History of pancreatic insufficiency
Other relevant medical history (e.g., pneumothorax, allergic bronchopulmonary aspergillosis – ABPA)
Hospitalizations related to CF
IV. Medications:
Current medications (inhalers, nebulized medications, pancreatic enzymes, vitamins, antibiotics for current or recent infection)
V. Social History:
Smoking history (active or secondhand smoke exposure)
Occupational exposures (inhalation hazards)
Social support system
VI. Physical Exam:
Vital signs (BP, HR, RR, Temp) – may be abnormal during pulmonary exacerbation
General appearance (nutritional status)
Respiratory exam:
Chest wall appearance (barrel chest)
Breath sounds (wheezing, crackles)
Oxygen saturation
Abdominal exam (assess for malnutrition, hepatomegaly)
VII. Laboratory Studies (consider as appropriate):
Sputum culture and sensitivities – to identify causative organisms during pulmonary exacerbations
Sputum cytology (if indicated) – to rule out other lung diseases
Sweat chloride test (confirmatory test for CF) – may not be done if diagnosis already established
Complete blood count (CBC) – may show inflammatory markers during exacerbations
Serum electrolytes – may be abnormal with malnutrition or dehydration
Liver function tests – may be abnormal with malnutrition or complications
VIII. Pulmonary Function Tests (PFTs):
Spirometry – measures lung volumes and airflow limitation
Body plethysmography (optional) – provides additional information on lung function
IX. Imaging Studies (consider as appropriate):
Chest X-ray – may show signs of hyperinflation, mucus plugging, or infiltrates
Chest CT scan (may be done for specific concerns) – may show bronchiectasis, fibrosis, or complications
X. Assessment:
Cystic fibrosis with stable disease or pulmonary exacerbation (if applicable) based on clinical presentation, history of disease, and PFT results (if available).
Nutritional status (well-nourished, underweight)
Severity of pulmonary disease based on PFT results and clinical symptoms.
Presence of pancreatic insufficiency based on clinical presentation and sweat test results (if not previously established).
XI. Plan:
Treatment plan depends on the severity of illness and specific needs:
Pulmonary exacerbations:
Antibiotics based on culture results
Increased airway clearance techniques (chest physiotherapy, nebulized medications)
Bronchodilators
Corticosteroids (may be needed)
Stable disease:
Maintenance medications (inhaled antibiotics, mucolytics, bronchodilators)
Regular airway clearance techniques
Pancreatic enzyme replacement therapy (if pancreatic insufficient)
Nutritional support (vitamins, dietary counseling)
Vaccinations: Ensure patient is up-to-date on all recommended vaccinations, including influenza and pneumococcal vaccines.
Referral to a pulmonologist or CF specialist may be indicated for complex cases or those requiring advanced therapies.
XII. Prognosis:
Discuss the chronic nature of CF and the importance of ongoing management to control symptoms, prevent complications, and optimize lung function.
Address the patient’s anxieties and concerns related to the disease.
XIII. Notes:
Include any additional observations or concerns, such as patient’s understanding of the treatment plan, adherence to medications and airway clearance, need for social support services, and the importance of annual reviews and monitoring lung function.
XIV. Resources:
Consider providing patient education materials on cystic fibrosis from reputable sources (e.g., Cystic Fibrosis Foundation, American Lung Association).