Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint: This section may vary depending on the severity of hypersensitivity pneumonitis.
Cough (dry or productive) – most common symptom
Shortness of breath (especially on exertion)
Fever (may be low-grade)
Fatigue, weakness
Chest tightness or pain
Night sweats (less common)
现病史 (xiàn bìng shǐ) History of Present Illness:
Onset, duration, and severity of symptoms
Recent hospitalizations or emergency department visits
Occupational history (potential antigen exposure) – crucial for diagnosis
Hobbies or activities that might involve antigen exposure (e.g., bird ownership, working with hay)
Recent travel or changes in environment
Smoking history (may worsen symptoms)
既往史 (jì wàng shǐ) Past Medical History:
Underlying lung diseases (e.g., asthma, COPD) – may increase susceptibility
Prior surgeries or procedures
History of allergies or atopy (increased risk)
Medications (current and recent)
家族史 (jiā zú shǐ) Family History:
Family history of lung diseases (not typically relevant for hypersensitivity pneumonitis, but may be helpful for overall risk assessment)
社会史 (shè huì shǐ) Social History:
Smoking history (see above)
Occupational exposures (see above)
Home environment (potential for antigen exposure like mold or birds)
查体 (chá tǐ) Physical Examination:
Vital signs (blood pressure, heart rate, temperature, oxygen saturation) – may be abnormal in severe cases
General appearance (respiratory distress)
Chest exam:
Crackles (abnormal lung sounds)
Wheezing (if airways are narrowed)
Fingertip clubbing (may be present in chronic cases)
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Complete blood count (CBC) – may show elevated white blood cells
Pulmonary function tests (PFTs) – may show restrictive pattern
Chest X-ray – may show infiltrates (areas of inflammation) in the lungs, findings may be subtle
High-resolution CT scan (HRCT) – more sensitive than X-ray for detecting infiltrates
Bronchoalveolar lavage (BAL) with cell differential – considered the gold standard for diagnosis, analyzes fluid from the lungs for specific immune cells
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
See “辅助检查 (fú zhu zhuān chá) Laboratory Tests” for imaging options.
诊断 (zhěn duàn) Diagnosis:
Hypersensitivity pneumonitis (based on clinical presentation, exposure history, and supportive tests)
Severity of hypersensitivity pneumonitis (based on symptoms and lung function)
Suspected antigen (if identified)
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Identify and avoid the offending antigen (most important step)
Medications:
Corticosteroids (to reduce inflammation) – mainstay of treatment
Bronchodilators (if wheezing is present)
Oxygen therapy (if needed)
Smoking cessation (if applicable)
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of disease, ability to avoid the antigen, and response to treatment.
Early diagnosis and antigen avoidance are crucial for a good prognosis.
Chronic cases with continued exposure may lead to lung scarring and functional decline.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of avoiding the identified antigen (critical for prevention and management)
Smoking cessation (if applicable)
Importance of medication adherence (if prescribed)
Warning signs of worsening symptoms (increased shortness of breath, fever)
Importance of regular follow-up to monitor lung function and response to treatment
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for the next appointment depends on the severity of illness and response to treatment.
Close monitoring of symptoms and lung function is essential.
Regular follow-up to ensure ongoing antigen avoidance and manage potential complications.