Date:
Patient:
MRN:
Clinician: (Nephrologist)
Reason for Visit:
Follow-up for FSGS
Evaluation of kidney function and proteinuria (protein in urine)
Monitoring for complications (hypertension, electrolyte imbalance)
Medication adjustment or response assessment
History of Present Illness:
Briefly describe the patient’s current status:
Age at diagnosis and presenting symptoms (proteinuria, hematuria – blood in urine, elevated blood pressure, edema – swelling)
Current level of proteinuria (quantitative measurement)
Presence and severity of edema or other complications
Response to current medications and any side effects
Past Medical History:
Underlying conditions that may contribute to FSGS (diabetes, obesity, autoimmune diseases)
History of kidney stones, urinary tract infections, or other kidney problems
Family History:
Family history of kidney disease (FSGS or other)
Social History:
Diet (high protein intake can worsen proteinuria)
Use of pain relievers (NSAIDs can worsen kidney function)
Smoking history (risk factor for FSGS progression)
Physical Exam:
Vital Signs: Blood pressure (elevated in FSGS-related hypertension)
General: Signs of fluid overload (edema)
Fundoscopy (eye exam): May reveal changes suggestive of hypertensive retinopathy
Labs:
Kidney function tests: Serum creatinine, glomerular filtration rate (GFR) to assess kidney function.
Urinalysis: Protein-to- creatinine ratio (UPCR) to quantify proteinuria.
Electrolytes: Monitor for imbalances like potassium wasting.
Consider mentioning other labs ordered based on suspicion:
Lipid panel – to assess cardiovascular health
Imaging:
Renal ultrasound: May be used to assess overall kidney size and structure.
Kidney biopsy (if performed previously): Histological confirmation of FSGS subtype.
Assessment:
Confirm the diagnosis of FSGS based on clinical presentation, proteinuria, and potentially kidney biopsy findings.
Identify the subtype of FSGS (primary vs. secondary) based on the underlying cause.
Evaluate the severity of kidney function decline and proteinuria.
Assess for complications of FSGS (hypertension, electrolyte imbalance, increased risk of infection).
Plan:
Outline the treatment plan to address proteinuria, slow kidney function decline, and manage complications:
Dietary modifications: Protein restriction and low-sodium diet to reduce workload on the kidneys.
Medications:
ACE inhibitors or ARBs – to lower blood pressure and protect kidney function.
Steroids or other immunosuppressants (for specific FSGS subtypes).
Diuretics (for edema management).
Management of underlying conditions: (e.g., diabetes control)
Referral to nephrologist specializing in FSGS: For complex cases or consideration of advanced therapies (plasma exchange).
Prognosis:
Briefly discuss the prognosis. The course of FSGS varies depending on the subtype and severity. Early diagnosis and treatment can help slow progression and preserve kidney function.
Consider mentioning the potential need for kidney replacement therapy (dialysis or transplant) in advanced stages.
Education:
Document any education provided to the patient regarding:
The nature of FSGS, its causes, and potential complications
The importance of dietary modifications and medication adherence
The importance of regular follow-up and monitoring
The potential need for future treatment options
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the disease and its management, and any concerns they may have.
Consider mentioning the importance of maintaining a healthy lifestyle to support kidney health (exercise, weight management, smoking cessation).
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a nephrologist for diagnosis and treatment recommendations.