Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
New or established minimal change disease (MCD)
(Specify) Nephrotic syndrome: Heavy proteinuria (>3.5 g/24 hours) with:
Hypoalbuminemia (low blood albumin)
Edema (fluid retention) – particularly periorbital (around eyes)
Hyperlipidemia (elevated cholesterol) – may be absent
History of Present Illness:
Onset, duration, and severity of symptoms:
Edema (location and severity)
Weight gain
Urinary symptoms (foamy urine, increased frequency)
Fatigue, malaise (general feeling of unwellness)
For established MCD:
Response to previous treatment (steroids)
Any recent infections or illnesses
Past Medical History:
Underlying medical conditions:
Infections (may precede MCD)
Autoimmune diseases (less common)
Medications (nonsteroidal anti-inflammatory drugs – NSAIDs)
History of malignancy (rarely associated with MCD in adults)
Family History:
Family history of kidney disease (not a strong risk factor for MCD)
Medications:
List all current medications, including any medications suspected to be a trigger (NSAIDs).
Social History:
Not typically relevant for MCD.
Physical Exam:
Vital signs: Assess for elevated blood pressure (may be present).
General examination: Assess for peripheral edema (particularly periorbital).
Skin examination: Look for striae (stretch marks) due to rapid weight gain (uncommon).
Laboratory Tests:
Urinalysis: Proteinuria (heavy protein in urine) with normal sediment (no blood or white blood cells).
Basic metabolic panel (BMP): Hypoalbuminemia and elevated cholesterol may be present.
Renal function tests: Serum creatinine may be normal or slightly elevated in severe cases.
Kidney Biopsy (gold standard for diagnosis but not always performed):
Reveals minimal glomerular changes on light microscopy with effacement of podocyte foot processes on electron microscopy.
Imaging Studies (not routinely used but may be indicated):
Abdominal ultrasound: May be used to rule out other causes of proteinuria (e.g., polycystic kidney disease).
Assessment:
Minimal change disease: Based on clinical presentation (nephrotic syndrome) and laboratory findings (heavy proteinuria, hypoalbuminemia) with supportive findings from a kidney biopsy (if performed).
Severity of proteinuria: Quantify the degree of proteinuria to guide treatment decisions.
Differential diagnoses: Consider and rule out other causes of nephrotic syndrome (e.g., focal segmental glomerulosclerosis, membranous nephropathy) based on clinical presentation, laboratory findings, and possible kidney biopsy results.
Plan:
Treatment: The mainstay of treatment is corticosteroids (prednisone).
Monitor response to treatment with repeat urinalysis to assess proteinuria levels.
Consider immunosuppressant medications if corticosteroids are ineffective or have significant side effects.
Address any underlying conditions that may have triggered MCD.
Dietary modifications (low-salt diet) may be recommended to manage blood pressure and edema.
Diuretics may be used to manage edema.
Follow-up: Schedule regular follow-up visits with urinalysis and possibly blood tests to monitor response to treatment, check for medication side effects, and assess for relapses.
Consultations: Referral to a nephrologist is recommended for diagnosis, treatment planning, and management of MCD.
Education:
Educate the patient about MCD, symptoms, causes, and treatment options.
Discuss the importance of medication adherence and potential side effects of corticosteroids.
Provide information about dietary modifications and the importance of a healthy lifestyle.
Advise on the importance of follow-up to monitor for relapses.
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. Minimal change disease can cause significant protein loss and requires prompt diagnosis and treatment to prevent complications