Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Encounter]
Subjective:
History of Present Illness:
Onset date and duration of symptoms:
Fever (duration, highest temperature)
Rash (location, character, duration)
Conjunctivitis (bilateral or unilateral, redness)
Changes in lips and oral mucosa (dryness, cracking, “strawberry tongue”)
Cervical lymphadenopathy (unilateral or bilateral, size)
Extremity changes (redness, swelling, desquamation)
Any recent illnesses or exposures
Medical History: Underlying medical conditions, allergies, medications
Objective:
Vital Signs: (BP, HR, RR, Temp)
Physical Exam:
General: Appearance of illness (fever, discomfort)
Skin: Rash distribution and characteristics
Eyes: Conjunctival injection (redness)
Mucous Membranes: Dryness, cracking of lips and oral mucosa
Neck: Cervical lymphadenopathy (size, tenderness)
Extremities: Redness, swelling, desquamation on palms and soles
Cardiovascular (if cardiac involvement suspected): Murmurs, arrhythmias
Laboratory:
Complete blood count (CBC) with differential (looking for elevated white blood cells and atypical lymphocytes)
C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) – elevated inflammatory markers
Electrolytes (may show abnormalities)
Liver function tests (may show abnormalities)
Urinalysis (may show abnormalities)
Additional testing as indicated (e.g., echocardiogram)
Assessment:
Kawasaki disease (complete vs. incomplete based on clinical criteria)
Stage of illness (acute, subacute, convalescent)
Presence of cardiac involvement (based on echocardiogram findings)
Risk stratification (high-risk vs. low-risk) for coronary artery abnormalities
Plan:
Treatment:
Initiate or continue treatment with intravenous immune globulin (IVIG) and aspirin based on current guidelines and disease severity.
Consider additional medications for refractory cases or specific complications.
Monitoring:
Close monitoring of vital signs, clinical symptoms, and laboratory tests.
Serial echocardiograms to assess for coronary artery abnormalities.
Consultation: Consider consultation with a pediatric cardiologist if cardiac involvement is suspected.
Education: Educate the patient and family about Kawasaki disease, treatment plan, potential complications, and follow-up needs.
Follow-up:
Schedule frequent follow-up appointments in the acute phase to monitor response to treatment and assess for complications.
Less frequent follow-up appointments in the convalescent phase to monitor for long-term complications.