Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint: Follow-up for lupus nephritis / New symptoms concerning lupus nephritis (specify)
History of Present Illness:
For follow-up visits, inquire about any new or worsening symptoms since the last encounter (e.g., fatigue, foamy urine, blood in urine, swelling in legs, decreased urine output).
Describe the character, duration, and severity of new symptoms.
Mention any recent illnesses or infections that may have triggered a lupus flare.
Briefly describe any changes in medications or adherence to treatment regimen.
Past Medical History:
Include the date of lupus diagnosis and the specific type, if known (e.g., lupus erythematosus (SLE), lupus nephritis class).
Mention any relevant past medical history, including:
Other autoimmune conditions
Prior episodes of lupus nephritis flares
Complications of lupus nephritis (e.g., hypertension, chronic kidney disease)
Medications:
List all current medications, including:
Immunosuppressive medications used for lupus nephritis (e.g., steroids, mycophenolate mofetil, cyclophosphamide)
Medications for blood pressure control
Medications for other lupus manifestations (e.g., hydroxychloroquine for skin involvement)
Social History:
Inquire about smoking history (smoking cessation is crucial for lupus patients).
Family History:
Inquire about a family history of autoimmune diseases.
Physical Exam:
Vital signs: Include temperature, blood pressure, and weight (monitor for weight gain suggestive of fluid overload).
General observation: Assess for signs of fatigue, edema (swelling) in legs or face.
Skin exam: Look for rashes characteristic of lupus.
Cardiovascular exam: Listen for heart murmurs (possible due to high blood pressure).
Laboratory Tests:
Urinalysis: Assess for proteinuria (excess protein in urine) and hematuria (blood in urine).
Renal function tests: Evaluate kidney function (creatinine, glomerular filtration rate).
Electrolytes: Monitor for electrolyte imbalances (can occur with diuretics used for blood pressure control).
Complete blood count (CBC): Monitor for cytopenias (low blood cell counts) – a potential side effect of some medications.
Antinuclear antibody (ANA) test: Positive ANA is a marker for lupus, but not specific for lupus nephritis.
Anti-dsDNA antibody test: Positive test can be indicative of active lupus nephritis.
Complement levels: Low complement levels may suggest ongoing inflammation.
Imaging Studies (if performed):
Kidney ultrasound: Assess for kidney size and abnormalities.
Kidney biopsy (if performed): The gold standard for definitive diagnosis of lupus nephritis class and disease activity.
Assessment:
Lupus activity: Describe current lupus activity based on symptoms, laboratory findings, and presence of a flare.
Lupus nephritis activity: Assess for active lupus nephritis based on clinical presentation, urinalysis findings, and kidney function.
Lupus nephritis class (if known): Mention the specific class of lupus nephritis based on kidney biopsy findings (if available).
Kidney function: Describe current kidney function and any changes since the last encounter.
Plan:
Treatment:
Outline the treatment plan based on the severity of lupus activity, kidney function, and lupus nephritis class. This may include:
Adjustment of immunosuppressive medications: Increase or decrease medications based on disease activity.
Blood pressure control: Medications to manage high blood pressure and protect kidney function.
Diuretics: May be used to remove excess fluid if present.
Dietary modifications: Sodium restriction and a healthy diet are crucial for managing blood pressure and overall health.
Monitoring: Schedule regular follow-up visits with laboratory tests and urinalysis to monitor lupus activity, kidney function, and medication side effects.
Referral to nephrologist: Consider referral to a kidney specialist for patients with advanced kidney disease or complex lupus nephritis management.
Education:
Educate the patient about lupus nephritis, the importance of medication adherence, healthy lifestyle choices (diet, exercise, sun protection), and the importance of recognizing and reporting signs of flares.