Date:
Patient:
MRN:
Clincian: (Rheumatologist, Internist)
Reason for Visit:
Follow-up for GCA
Evaluation of symptoms and response to treatment
Review of laboratory and imaging results
Discussion of treatment plan and potential complications
History of Present Illness:
Briefly describe the patient’s current status:
Duration of symptoms (headaches, scalp tenderness, jaw claudication – difficulty chewing, vision loss)
Severity and characteristics of symptoms
Response to previous treatment approaches (corticosteroids)
Past Medical History:
Underlying conditions (polymyalgia rheumatica often co-occurs with GCA)
Vascular risk factors (hypertension, hyperlipidemia)
Social History:
Smoking history (strong risk factor for GCA)
Physical Exam:
Vital Signs: May be normal or abnormal depending on the severity of inflammation.
Temporal artery exam: Tenderness, thickening, or decreased pulsation of the temporal arteries.
Other findings related to complications (visual loss exam).
Labs:
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): Elevated levels are suggestive of inflammation, but not specific for GCA.
Blood tests to rule out other causes of symptoms (complete blood count – CBC, electrolytes).
Consider mentioning other labs ordered as needed (temporal artery biopsy for definitive diagnosis).
Imaging:
Temporal artery ultrasound (US) or Doppler: May show abnormal findings suggestive of vasculitis, but not always definitive.
Consider mentioning other imaging studies performed (CT angiography) depending on clinical suspicion.
Assessment:
Summarize the diagnosis and disease activity:
Confirmation of GCA diagnosis based on clinical presentation, laboratory findings, and imaging results (if available).
Disease activity level based on ongoing symptoms and inflammatory markers.
Plan:
Outline the treatment plan based on the assessment:
High-dose corticosteroids: Prednisone is the mainstay of treatment to suppress inflammation and prevent complications.
Tapering corticosteroids: Gradual reduction of steroid dose as tolerated to minimize side effects.
Adjunctive therapy: Low-dose aspirin may be considered to reduce vascular risk.
Consider mentioning the importance of monitoring for medication side effects (bone density scans, blood sugar checks).
Prognosis:
Briefly discuss the prognosis. Early diagnosis and treatment are crucial to prevent complications like vision loss. With treatment, most patients experience significant improvement in symptoms. However, GCA can be a relapsing-remitting condition, requiring long-term management.
Emphasize the importance of ongoing monitoring and adherence to treatment.
Education:
Document any education provided to the patient regarding:
The nature of GCA, its symptoms, and potential complications
The importance of taking medications as prescribed and potential side effects
Warning signs and symptoms that may require urgent evaluation (worsening vision)
The importance of a healthy lifestyle (smoking cessation, balanced diet)
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about medication side effects, long-term management, or vision loss.
Consider mentioning the importance of sun protection due to increased sun sensitivity with steroid use.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a rheumatologist or internist for diagnosis, treatment recommendations, and prognosis.