Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Encounter]
Subjective:
JIA Diagnosis and Onset:
Type of JIA (systemic, oligoarticular, polyarticular, enthesitis-related, psoriatic)
Age at diagnosis
Current Symptoms:
Joint pain (location, severity, duration)
Morning stiffness (duration)
Limiting function (difficulty with daily activities)
Fever (present/absent, duration)
Rash (present/absent, location)
Fatigue (severity)
Eye involvement (present/absent, symptoms)
Medications: Current medications for JIA and any side effects
Objective:
Vital Signs: (BP, HR, RR, Temp)
Physical Exam:
General: Appearance of illness (fever, rash)
Musculoskeletal: Joint tenderness, swelling, range of motion limitations
Skin: Presence of rash (psoriasis)
Eyes: Evidence of uveitis (if present)
Laboratory: (as indicated)
Complete blood count (CBC) with differential (looking for anemia or elevated inflammatory markers)
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) (inflammatory markers)
Antinuclear antibody (ANA) testing (may be positive in some JIA subtypes)
Rheumatoid factor (RF) testing (usually negative in JIA)
Imaging: (as indicated)
X-rays of affected joints
Ultrasound of joints
MRI of joints (for detailed evaluation or suspected complications)
Assessment:
Juvenile idiopathic arthritis (confirmed type)
Disease activity (active vs. inactive) based on joint symptoms, inflammatory markers, and physician global assessment
Functional limitations due to JIA
Presence of extra-articular manifestations (fever, rash, eye involvement)
Plan:
Medications:
Continue/adjust current medications based on disease activity and response.
Discuss potential side effects and monitoring plan.
Physical and occupational therapy:
Referral for physical and occupational therapy to improve joint function, strength, and range of motion.
Patient education:
Educate the patient and family about JIA, treatment options, and disease management strategies.
Discuss the importance of adherence to medications and therapy appointments.
Provide resources for support groups or educational materials.
Laboratory and imaging follow-up:
Schedule follow-up labs (inflammatory markers) and imaging (as needed) to monitor disease activity and response to treatment.
Referral (if indicated): Consider referral to a pediatric rheumatologist for specialized management if:
Complex or severe disease course
Difficulty achieving disease control
Suspected complications (joint damage, uveitis)
Follow-up:
Schedule next appointment in [interval] weeks to monitor disease activity, adjust treatment plan as needed, and address any concerns.