Date:
Patient:
MRN:
Clincian: (Pediatrician, Rheumatologist)
Reason for Visit:
Follow-up for Henoch-Schönlein purpura (HSP)
Evaluation of symptoms and response to treatment
Review of laboratory and imaging results (if performed)
Assessment for complications
History of Present Illness:
Briefly describe the child’s current status:
Persistence or improvement of symptoms (purpuric rash, abdominal pain, joint pain, swelling)
Presence of new or worsening symptoms (hematuria – blood in urine, testicular pain)
Any recent infections (potential triggers)
Past Medical History:
Underlying medical conditions (allergies, autoimmune diseases)
Previous hospitalizations or illnesses
Family History:
Family history of HSP (uncommon)
Social History:
Recent vaccinations (rare association)
Exposure to other illnesses
Physical Exam:
Vital Signs: May be normal unless complications arise (severe abdominal pain).
Skin exam: Palpable purpuric rash on buttocks, legs, and extensor surfaces.
Abdominal exam: Tenderness to palpation may be present.
Joint exam: Assess for swelling, tenderness, and limitation of movement in affected joints.
Labs:
Routine laboratory tests are not diagnostic for HSP but may be helpful:
Urinalysis: May show microscopic hematuria (blood in urine).
Consider mentioning other labs ordered as needed (inflammatory markers like CRP, ESR)
Consider mentioning kidney function tests if there is concern for kidney involvement.
Imaging:
Imaging studies are not typically needed for diagnosis.
Consider mentioning abdominal ultrasound if severe abdominal pain persists to rule out other causes.
Assessment:
Summarize the diagnosis of HSP based on clinical presentation (rash, joint pain, abdominal pain) and consider mentioning any supportive laboratory findings.
Assess disease activity based on symptom improvement or worsening.
Plan:
Outline the treatment plan based on the severity of symptoms:
Supportive care:
Pain management with medications (NSAIDs – consider using with caution due to potential kidney side effects)
Rest
Adequate hydration
Corticosteroids: May be used in severe cases or with joint involvement to reduce inflammation.
Prognosis:
Briefly discuss the prognosis. Most children with HSP recover fully within a few weeks to months.
Emphasize the importance of monitoring for complications (arthritis, nephritis – kidney inflammation)
Education:
Document any education provided to the parents/guardians regarding:
The nature of HSP and its potential causes
The importance of pain management and monitoring for complications
The potential for relapses, although uncommon
Reassurance that most children recover fully
Notes:
Include any additional relevant information not covered above, such as the parents’ understanding of the diagnosis and treatment plan, and any concerns they may have about medication side effects, activity limitations, or the emotional impact on the child.
Consider the need for school modifications or support services if the child’s activity is limited.
Disclaimer: This is a template and should be adapted to the specific needs of each child. It is important to consult with a pediatrician or rheumatologist for diagnosis, treatment recommendations, and prognosis.