Patient: [Patient Name]
Date: [Date of Encounter]
I. Chief Complaint:
Cough (productive or non-productive, duration)
Shortness of breath (onset, exertion-related)
Pleuritic chest pain (sharp, stabbing, worse with inspiration)
Fatigue
Other symptoms (weight loss, fever, malaise)
II. History of Present Illness:
Duration and progression of symptoms
Functional limitations due to respiratory symptoms
Prior hospitalizations for respiratory illness
III. Past Medical History:
Underlying connective tissue disease (CTD) diagnosis (e.g., systemic sclerosis, rheumatoid arthritis)
Date of CTD diagnosis
Other medical conditions (pulmonary fibrosis, smoking history)
Current medications (CTD medications, immunosuppressants)
IV. Social History:
Smoking history (current smoker, former smoker, never smoker)
Environmental exposures (dust, fumes, occupational hazards)
V. Physical Exam:
Vital signs:
Temperature (oral, rectal, or tympanic)
Blood pressure
Heart rate
Respiratory rate (tachypnea may be present)
Oxygen saturation (hypoxemia possible)
General: Appearance of illness (mild, moderate, severe)
Respiratory:
Chest expansion (decreased on affected side)
Tactile fremitus (decreased or absent over consolidation)
Percussion (dullness over consolidation)
Auscultation (crackles, inspiratory crackles)
Clubbing (杵状指; chùy zhuàng zhǐ) (fingers) – possible sign of chronic lung disease
VI. Assessment:
CTD-ILD diagnosis based on clinical presentation, CTD history, and imaging studies
CTD-ILD subtype (if possible)
Disease severity (mild, moderate, severe) based on symptoms, functional limitations, and imaging findings
Acute exacerbation vs. disease progression
VII. Diagnostic Studies (consider as appropriate):
Chest X-ray (infiltrates, reticular opacities)
High-resolution CT scan (HRCT) of chest (detailed evaluation of lung involvement)
Pulmonary function tests (PFTs) (assess lung volumes, airflow limitation, diffusion capacity)
Bronchoscopy with bronchoalveolar lavage (BAL) (may be indicated in specific cases)
Autoantibody testing (specific to underlying CTD)
VIII. Plan:
Treatment plan depends on severity, CTD type, and specific findings:
Management of underlying CTD with disease-specific medications
Immunosuppressive therapy (corticosteroids, other immunosuppressants) – tailored to CTD and lung involvement
Anti-fibrotic medications (if indicated for specific CTD-ILD subtypes)
Oxygen therapy (if hypoxemia present)
Pulmonary rehabilitation program (improve exercise capacity and quality of life)
Respiratory support (nebulizer treatments, bronchodilators) – if needed
Follow-up schedule (frequency depends on disease severity and response to treatment)
IX. Prognosis:
Discuss the potential course of CTD-ILD, including potential for exacerbations and importance of ongoing management.
X. Notes:
Include any additional observations or concerns, such as response to initial treatment, potential complications (pulmonary hypertension, respiratory failure), and need for additional consultations (pulmonologist, rheumatologist).
XI. Resources:
Consider providing patient education materials on CTD-ILD from reputable sources (e.g., American Lung Association, National Institutes of Health (NIH) ).