Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint):
Describe the patient’s main presenting symptoms, typically a triad of:
High spiking fever (often daily) lasting at least 2 weeks
Polyarthralgia (joint pain in multiple joints, often migratory)
Characteristic rash (evanescent salmon-colored maculopapular rash, typically on the trunk and extremities)
May also report:
Fatigue
Sore throat
Lymphadenopathy (enlarged lymph nodes)
Pleuritis (inflammation of the pleura, causing chest pain)
Pericarditis (inflammation of the pericardium, causing chest pain)
History of Present Illness:
Onset and duration of symptoms
Daily pattern of fever (spiking vs. constant)
Characteristics of the rash (location, appearance, duration)
Joint pain (location, severity, migratory pattern)
Associated symptoms (fatigue, sore throat, etc.)
Past medical history (any inflammatory conditions, autoimmune diseases)
Past surgical history
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate) – Fever is typically prominent.
General examination: Assess for overall well-being and signs of inflammation (e.g., joint swelling).
Musculoskeletal examination: Tenderness, swelling, and warmth in multiple joints.
Skin examination: Evaluate the rash for its characteristics and distribution.
Cardiopulmonary examination: Listen for signs of pleuritis or pericarditis (if present).
Laboratory Findings:
Elevated inflammatory markers: ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein) are typically significantly elevated.
Leukocytosis (high white blood cell count): May be present.
Ferritin: May be elevated, although not specific for AOSD.
Autoimmune antibodies: ANA (antinuclear antibody) testing may be positive in some cases, but is not diagnostic for AOSD.
Other tests (may be ordered to rule out other diagnoses): Rheumatoid factor, anti-citrullinated protein antibody (ACPA), infectious workup (blood cultures, viral serologies)
Imaging Studies (may be ordered to assess joint involvement or rule out other diagnoses):
X-rays: May show joint inflammation (erosions in later stages).
MRI scans: May provide more detailed information on joint inflammation and potential complications.
Assessment:
Diagnose adult-onset Still’s disease based on clinical criteria (fever, polyarthralgia, rash) and elevated inflammatory markers, considering exclusion of other diagnoses.
Consider the severity of the disease and potential organ involvement (pleuritis, pericarditis).
Plan:
First-line treatment:
Glucocorticoids (steroids): Prednisone is typically the mainstay of treatment to reduce inflammation and improve symptoms.
Disease-modifying antirheumatic drugs (DMARDs): Methotrexate is often used in combination with steroids to control the disease long-term and reduce steroid dependence.
Nonsteroidal anti-inflammatory drugs (NSAIDs): Can help manage pain and inflammation.
Second-line therapy (if first-line fails):
Biological agents (e.g., TNF-alpha inhibitors) may be considered for patients with severe or refractory disease.
Supportive care: Rest, physical therapy, and nutritional support are important for managing symptoms and improving quality of life.
Consultations (may be needed depending on the case):
Rheumatologist (specialist in autoimmune diseases)
Cardiologist (if pericarditis is suspected)
Pulmonologist (if pleuritis is suspected)
Progress Notes:
Document response to treatment, including changes in fever, joint pain, rash, and inflammatory markers.
Monitor for side effects of medications.
Assess functional abilities and quality of life.
Adjust the treatment plan as needed based on the patient’s response and disease activity.
Prognosis:
AOSD is a chronic condition, but early diagnosis and treatment can help control symptoms, prevent complications, and improve long-term outcomes.
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Early diagnosis and treatment by a rheumatologist are crucial for managing AOSD and improving the patient’