Date:
Patient:
MRN:
Clinician: (Neurologist, Neuromuscular Specialist)
Reason for Visit:
Follow-up for FSHD
Evaluation of disease progression
Management of symptoms (weakness, fatigue, pain)
Physical and occupational therapy evaluation/reassessment
Assistive device needs assessment
History of Present Illness:
Briefly describe the patient’s current status:
Progression of muscle weakness (facial, shoulder girdle, upper arms)
Functional limitations in daily activities (dressing, grooming, ambulation)
Frequency and severity of fatigue
Pain (location, character, impact on function)
Emotional well-being (depression, anxiety)
Past Medical History:
Include any relevant past medical conditions, such as:
Previous surgeries for contractures or other complications
History of falls
Family History:
Presence of FSHD in first-degree relatives
Social History:
Occupation and impact of FSHD on work activities
Social support system
Physical Exam:
Muscle strength testing (manual muscle testing) of facial muscles, shoulder girdle, and upper arms
Range of motion assessment of affected joints
Gait assessment (if weakness affects ambulation)
Balance and coordination testing
Labs:
Genetic testing results for FSHD confirming the diagnosis (if available)
Consider mentioning other labs if performed, such as creatine kinase (CK) levels (may be elevated in muscle diseases).
Imaging:
Imaging studies are not routinely used for diagnosis but may be performed to assess complications (e.g., MRI for spinal involvement).
Assessment:
Confirm the diagnosis of FSHD based on clinical features, family history, and genetic testing (if available).
Assess the stage of disease progression based on muscle weakness and functional limitations.
Evaluate for complications of FSHD, such as contractures, scoliosis, and respiratory insufficiency (in severe cases).
Plan:
Outline the treatment plan, focusing on supportive measures to manage symptoms and maintain function:
Physical therapy: Regular physical therapy sessions to improve muscle strength, flexibility, and range of motion.
Occupational therapy: Training on adaptive techniques and assistive devices to maximize independence in daily activities.
Pain management: Medications (muscle relaxants, analgesics) and non-pharmacological approaches (heat therapy, massage).
Speech therapy (if facial weakness affects speech)
Genetic counseling (if not already completed) to discuss the disease and family planning.
Prognosis:
Briefly discuss the prognosis, which is variable. FSHD is a progressive disease, but the rate of progression can vary significantly between individuals.
Education:
Document any education provided to the patient regarding:
The nature of FSHD and its progression
Importance of physical and occupational therapy
Strategies to manage symptoms (pain, fatigue)
Support groups and resources available for FSHD patients
Notes:
Include any additional relevant information not covered above, such as the patient’s goals for therapy and any psychosocial concerns.
Consider mentioning the importance of regular follow-up to monitor disease progression and adjust management as needed.
Disclaimer: This is a template and should be adapted to the specific needs of each patient.