Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint:
This section will vary depending on the severity of IPF. Common complaints may include:
Dyspnea (shortness of breath), especially on exertion
Dry cough (unproductive)
Fatigue
Weight loss (unintentional)
现病史 (xiàn bìng shǐ) History of Present Illness:
Age at onset of symptoms
Duration and progression of symptoms
Activity limitations due to dyspnea
History of hospitalizations or emergency department visits for respiratory problems
既往史 (jì wàng shǐ) Past Medical History:
Smoking history (major risk factor)
Occupational exposures (dust, fumes)
Prior surgeries or procedures (especially thoracoabdominal)
History of autoimmune diseases (e.g., rheumatoid arthritis)
Gastroesophageal reflux disease (GERD) (potential risk factor)
家族史 (jiā zú shǐ) Family History:
Family history of lung disease (uncommon)
社会史 (shè huì shǐ) Social History:
Current smoking status (cessation counseling is crucial)
Occupational exposures (continued or past)
查体 (chá tǐ) Physical Examination:
Vital signs:
Respiratory rate (may be increased)
Oxygen saturation (may be decreased on exertion)
General appearance:
Signs of respiratory distress (pursed-lip breathing, use of accessory muscles)
Finger clubbing (late sign)
Cardiovascular exam:
Signs of cor pulmonale (right heart dysfunction due to lung disease)
Pulmonary exam:
Crackles (abnormal breath sounds)
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Complete blood count (CBC) – may show anemia
Electrolytes – to assess for electrolyte imbalances
Liver function tests (LFTs) – to assess for potential drug side effects
Autoimmune antibodies (depending on suspicion)
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Chest X-ray: may show signs of interstitial lung disease.
High-resolution CT scan of the chest: essential for diagnosis, showing characteristic features of IPF.
Pulmonary function tests (PFTs): may show decreased lung volumes and impaired gas exchange.
诊断 (zhěn duàn) Diagnosis:
Idiopathic pulmonary fibrosis (based on clinical presentation, high-resolution CT scan findings, and exclusion of other causes).
分期 (fēn qī) Staging:
Discuss the disease stage based on lung function tests and/or specific scoring systems (e.g., forced vital capacity (FVC)).
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Medications:
Antifibrotic medications (e.g., pirfenidone, nintedanib) – may slow disease progression.
Oxygen therapy (if needed)
Pulmonary rehabilitation to improve exercise tolerance and quality of life.
Treating GERD: If present, addressing it can be helpful.
Lung transplantation: Considered in severe cases.
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of IPF, disease stage, lung function, and response to treatment.
IPF is a progressive disease, but early diagnosis and treatment can improve quality of life and slow progression.
Regular follow-up is essential to monitor symptoms, lung function, and discuss treatment options.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of smoking cessation (if applicable)
Importance of medication adherence
Importance of pulmonary rehabilitation
Recognizing signs of worsening symptoms (increased dyspnea, decreased activity tolerance)
Support groups and resources for patients with IPF
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for the next appointment depends on the severity of IPF and disease stage.
Regular follow-up is crucial to monitor symptoms, lung function, and adjust treatment as needed.