Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint:
This section will focus on symptoms related to bile duct obstruction:
Jaundice (yellowing of the skin and eyes)
Fatigue
Dark urine
Pruritus (itching)
Right upper quadrant abdominal pain (less common)
现病史 (xiàn bìng shǐ) History of Present Illness:
Age at onset of symptoms
Duration and progression of symptoms
Severity of symptoms (e.g., degree of jaundice, pruritus)
Hospital admissions for complications (cholangitis)
既往史 (jì wàng shǐ) Past Medical History:
Underlying medical conditions:
Autoimmune diseases (e sicca syndrome, autoimmune pancreatitis)
History of other IgG4-related manifestations (e.g., parotid swelling)
Prior surgeries (abdominal surgeries, biliary interventions)
History of infections (potential triggers)
家族史 (jiā zú shǐ) Family History:
Family history of autoimmune diseases (uncommon)
社会史 (shè huì shǐ) Social History:
Smoking history (may worsen prognosis)
Alcohol intake
查体 (chá tǐ) Physical Examination:
Vital signs (may be normal or show signs of infection)
Jaundice (scleral and skin icterus)
Right upper quadrant tenderness (less common)
Lymphadenopathy (swollen lymph nodes) – uncommon
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Liver function tests (LFTs):
Elevated alkaline phosphatase (ALP) and bilirubin are suggestive.
IgG4 level: elevated in most IgG4-RD cases, but not diagnostic alone.
Autoimmune markers (e.g., ANA, ANCA) – may be elevated but not specific for IgG4-SC.
Inflammatory markers (ESR, CRP) – may be elevated.
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
ERCP (Endoscopic retrograde cholangiopancreatography):
Visualizes the bile ducts and may be used to obtain tissue samples.
MRCP (Magnetic resonance cholangiopancreatography):
Non-invasive imaging of the bile ducts, often preferred initially.
CT scan (abdomen) – may show bile duct dilatation and liver involvement.
组织活检 (zǔ zhī huó jiǎn) Biopsy:
Liver biopsy or tissue samples obtained during ERCP are crucial for confirming the diagnosis.
诊断 (zhěn duàn) Diagnosis:
IgG4-related sclerosing cholangitis (based on clinical presentation, characteristic imaging findings, serological features, and histopathological confirmation).
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Glucocorticoids (prednisone) are the mainstay of treatment to suppress inflammation.
Ursodeoxycholic acid (UDCA) – a bile acid medication to improve bile flow.
Placement of biliary stents to relieve biliary obstruction (may be temporary or permanent).
Rituximab (B-cell depleting therapy) may be used in some cases, especially for relapses or maintenance therapy.
Liver transplantation: considered in end-stage liver disease.
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of bile duct obstruction, response to treatment, and potential for relapses.
Early diagnosis and treatment can improve long-term outcomes and prevent complications like liver cirrhosis.
Regular follow-up is essential to monitor disease activity, adjust treatment as needed, and screen for complications.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of medication adherence and potential side effects of steroids.
Importance of a healthy diet and avoiding alcohol.
Recognizing signs of flares (worsening jaundice, pruritus) and seeking medical attention promptly.
Support groups and resources for patients with IgG4-SC
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for the next appointment depends on disease severity, response to treatment, and presence of complications.
Regular follow-up is crucial to monitor disease activity, adjust treatment as needed, and screen for complications.