Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint:
This section will vary depending on the affected organ(s). Common complaints may include:
Swollen glands (e.g., parotid, lacrimal)
Abdominal pain (pancreatitis, biliary involvement)
Retroperitoneal fibrosis (back pain, ureteric obstruction)
Sclerosing cholangitis (jaundice, fatigue)
Peripheral neuropathy (numbness, weakness)
Respiratory symptoms (cough, shortness of breath)
History of Present Illness:
Age at onset of symptoms
Duration and progression of symptoms
Specific symptoms related to the affected organ system(s)
History of relapses or flares
Past Medical History:
Underlying medical conditions (autoimmune diseases, allergies)
Prior surgeries (relevant to the affected organ)
History of infections (potential triggers)
Family History:
Family history of autoimmune diseases (uncommon)
Social History:
Smoking history (may worsen some presentations)
Occupational exposures (potential triggers in some cases)
Physical Examination:
Vital signs (may be normal or show signs of inflammation)
General appearance (evidence of organ involvement – e.g., parotid swelling, jaundice)
Lymphadenopathy (swollen lymph nodes) – depending on location
Organ-specific examination (e.g., abdominal palpation for masses, lung sounds)
Laboratory Tests:
Serum IgG4 level: elevated in most IgG4-RD cases, but not diagnostic alone
Autoimmune markers (e.g., ANA, ANCA) – may be elevated but not specific for IgG4-RD
Inflammatory markers (ESR, CRP) – may be elevated
Imaging Studies:
Imaging studies will depend on the suspected organ involvement:
CT scan (chest, abdomen, pelvis)
MRI scan (depending on the organ)
PET scan (may help identify active disease)
Sialography (salivary glands)
Cholangiography (bile ducts)
Biopsy:
Obtaining tissue samples from the affected organ(s) is crucial for definitive diagnosis.
诊断 (zhěn duàn) Diagnosis:
IgG4-related disease (based on clinical presentation, serology, imaging findings, and histopathological confirmation)
Specify the involved organ system(s): (e.g., IgG4-related sclerosing cholangitis, IgG4-related pancreatitis)
Treatment Plan:
Glucocorticoids (prednisone) are the mainstay of treatment to suppress inflammation.
Rituximab (B-cell depleting therapy) may be used in some cases, especially for relapses or maintenance therapy.
Treatment duration depends on disease severity and response.
Prognosis:
Discuss the outlook based on the severity of organ involvement, response to treatment, and potential for relapses.
Early diagnosis and treatment can improve outcomes and prevent organ damage.
Regular follow-up is essential to monitor disease activity, adjust treatment, and screen for complications.
Patient Education:
Importance of medication adherence and potential side effects of steroids.
Importance of a healthy lifestyle (diet, exercise).
Recognizing signs of flares (worsening symptoms) and seeking medical attention promptly.
Support groups and resources for patients with IgG4-RD
Next Follow-up:
Schedule for the next appointment depends on disease severity and treatment response.
Regular follow-up is crucial to monitor disease activity, adjust treatment as needed, and screen for complications.