Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
New or follow-up for microscopic polyangiitis (MPA)
(Specify) Symptoms suggestive of active disease:
Constitutional symptoms (fever, fatigue, weight loss)
Arthralgias (joint pain) or arthritis (joint swelling)
Respiratory symptoms (cough, shortness of breath)
Renal manifestations (blood in urine, protein in urine, elevated creatinine)
May be asymptomatic in remission
History of Present Illness:
Onset, duration, and severity of symptoms.
Progression or improvement of symptoms since last visit.
Functional limitations due to symptoms.
Past Medical History:
Underlying medical conditions:
Previous infections (may trigger MPA)
Autoimmune diseases (e.g., Sjögren’s syndrome)
Underlying lung disease (e.g., chronic obstructive pulmonary disease – COPD)
Medications:
List all current medications, including immunosuppressive medications used for MPA treatment.
Social History:
Smoking history (risk factor).
Environmental exposures (e.g., silica dust).
Family History:
Family history of autoimmune diseases (not a strong risk factor for MPA).
Physical Exam:
Vital signs: Assess for fever, tachycardia (rapid heart rate), and tachypnea (rapid breathing).
General examination: Assess for muscle wasting, joint swelling, and signs of skin involvement (rare).
Lung examination: Listen for crackles (rales) suggestive of alveolar infiltrates.
Cardiovascular examination: Assess for signs of heart failure (if myocarditis is present).
Laboratory Tests:
Complete blood count (CBC): May reveal anemia or elevated white blood cell (WBC) count.
Basic metabolic panel (BMP): May show elevated creatinine or electrolyte abnormalities.
Urinalysis: May reveal proteinuria or hematuria.
Antineutrophil cytoplasmic antibodies (ANCA): Positive ANCA testing, particularly MPO-ANCA, is suggestive of MPA but not diagnostic.
Inflammatory markers: Elevated C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) may be present during active disease.
Imaging Studies (as indicated):
Chest X-ray: May show infiltrates suggestive of alveolar hemorrhage or interstitial lung disease.
High-resolution CT scan (chest): Can provide a more detailed evaluation of lung involvement.
Renal ultrasound: May reveal abnormalities of kidney size or echogenicity.
Assessment:
Microscopic polyangiitis: Based on clinical presentation, laboratory findings (including ANCA testing), and imaging studies.
Disease activity: Evaluate whether the disease is in active phase, remission, or relapses.
Severity of organ involvement: Assess the degree of involvement in lungs, kidneys, and other organs.
Plan:
Treatment of active MPA is multipronged:
Induction therapy: High-dose immunosuppressants (e.g., cyclophosphamide) combined with corticosteroids to suppress inflammation and prevent organ damage.
Maintenance therapy: Lower-dose immunosuppressants to prevent relapses.
Treatment of specific organ involvement: Additional medications may be needed for respiratory or renal issues.
Monitoring: Regular follow-up visits with laboratory tests and imaging studies to monitor response to treatment and disease activity.
Consultations: Referral to a rheumatologist for management of MPA and coordination of care with other specialists (e.g., pulmonologist, nephrologist) if organ involvement is significant.
Education:
Educate the patient about MPA, symptoms, risk factors, and the importance of adherence to treatment.
Discuss the potential side effects of immunosuppressive medications.
Provide information about support groups and resources for patients with chronic illnesses.
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. Microscopic polyangiitis is a serious autoimmune disease. Early diagnosis and prompt treatment are crucial to prevent organ damage and improve long-term outcomes