Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint: Follow-up for localized scleroderma / New symptoms related to localized scleroderma (specify)
History of Present Illness:
For follow-up visits, inquire about any new or worsening symptoms since the last encounter (e.g., increased skin thickening, joint pain, functional limitations).
For new presentations, describe the onset, location, character, and duration of new symptoms (e.g., new areas of skin involvement, pruritus, contractures).
Briefly mention any recent events or triggers that may have worsened symptoms (e.g., trauma, sun exposure).
Past Medical History:
Include the date of localized scleroderma diagnosis.
Mention the specific subtype of localized scleroderma, if known (e.g., morphea, linear scleroderma).
List any relevant past medical history (e.g., autoimmune conditions, history of connective tissue disease).
Medications:
List all current medications, including those specifically used for localized scleroderma (e.g., topical corticosteroids, immunosuppressants).
Social History:
Briefly inquire about occupational exposures (relevant for some subtypes like linear scleroderma).
Family History:
Inquire about any family history of autoimmune diseases.
Physical Exam:
Skin exam: Describe the location, extent, and characteristics of skin lesions (e.g., induration, color changes, surface texture).
Musculoskeletal exam: Assess for joint tenderness, range of motion limitations, contractures.
Evaluate for functional limitations in daily activities (dressing, ambulation).
Laboratory Tests (if recent):
Not routinely required for diagnosis of localized scleroderma, but may be performed to rule out other conditions or assess for systemic involvement.
These may include:
Antinuclear antibody (ANA): Often positive in localized scleroderma, but not specific for the diagnosis.
Complete blood count (CBC): May reveal inflammatory markers if there is active inflammation.
Imaging Studies (if performed):
Imaging studies are not essential for diagnosis but may be used to assess disease extent or rule out other conditions. Examples include:
Skin ultrasound: Can assess the depth of skin involvement.
MRI: May be used to evaluate deeper tissue involvement or assess for joint inflammation.
Assessment:
Diagnosis: Confirm the diagnosis of localized scleroderma and mention the specific subtype if known.
Disease activity: Briefly describe the perceived disease activity based on the presence of new symptoms or progression of existing lesions.
Plan:
Treatment:
Outline the treatment plan based on disease severity, subtype, and individual needs. This may include:
Topical therapy: Topical corticosteroids are the mainstay of treatment for localized scleroderma.
Physical therapy: To maintain joint mobility and improve function.
Systemic therapy (immunosuppressants): May be considered for more severe cases with deeper tissue involvement or significant functional limitations.
Phototherapy: Ultraviolet light therapy may be used in some cases.
Patient education: Educate the patient about the disease, treatment options, potential complications, and sun protection measures.
Follow-up:
Schedule the next clinic visit for follow-up based on disease activity and treatment response.
Advise the patient to report any new or worsening symptoms promptly.