Date:
Patient:
Reason for Visit:
Follow-up for Sjögren’s syndrome
Assessment of symptoms (dryness, fatigue, pain)
Evaluation of disease activity and potential complications
Management plan discussion
History:
Presenting Illness:
Date of initial Sjögren’s syndrome diagnosis
Severity and duration of dry eyes (burning, irritation, foreign body sensation) and dry mouth (difficulty swallowing, frequent thirst)
Additional symptoms (fatigue, joint pain, swelling)
Impact of symptoms on daily life (work, social activities)
Past Medical History (PMH):
Underlying autoimmune conditions (e.g., rheumatoid arthritis, lupus)
Medications (prescription and over-the-counter) – some medications can worsen dryness
Social History:
Smoking history (smoking can worsen dryness)
Use of air conditioning or dry heat (can exacerbate symptoms)
Physical Exam:
General: Assess for overall health, signs of fatigue.
Eyes: Evaluate tear production (Schirmer’s test) and examine for dryness, redness, or inflammation.
Mouth: Check for salivary flow (unstimulated and stimulated saliva production) and signs of dryness.
Musculoskeletal: Assess for joint tenderness, swelling, or limited mobility.
Diagnostic Tests (may be ordered depending on clinical suspicion):
Autoantibody testing: Anti-SSA (Ro) and anti-SSB (La) antibodies are highly suggestive of Sjögren’s syndrome.
Schirmer’s test: Measures tear production to assess dry eye severity.
Oral dryness tests: Measures salivary flow to assess dry mouth severity.
Urinalysis (may be ordered): To rule out other causes of dry eyes and mouth.
Assessment:
Disease activity: Based on symptom severity, physical exam findings, and laboratory results (e.g., autoantibodies).
Potential complications: Evaluate for risks associated with Sjögren’s syndrome, such as dental problems, eye infections, or lymphoma (rare).
Impact on daily life: Assess how symptoms affect the patient’s overall well-being and ability to function.
Plan:
Management approach based on symptom severity and individual needs:
Treatment for dryness:
Artificial tears (eye drops) for dry eyes.
Saliva substitutes or stimulants for dry mouth.
Moisture chamber devices (humidifiers) to improve indoor air humidity.
Medications:
Hydroxychloroquine (plaquenil) – may help with joint pain, fatigue, and some dry eye symptoms.
Immunosuppressive medications (in severe cases) to control inflammation.
Lifestyle modifications:
Smoking cessation (if applicable).
Avoiding dry environments and using air humidifiers.
Regular dental care to prevent dental problems.
Management of other conditions: Address any underlying autoimmune conditions that may contribute to symptoms.
Patient education: Provide information about Sjögren’s syndrome, its causes, and treatment options.
Explain the importance of using artificial tears and saliva substitutes regularly.
Discuss lifestyle modifications to manage dryness and improve comfort.
Address potential complications and the importance of regular follow-up.
Follow-up:
Schedule for follow-up appointments based on disease activity:
More frequent visits for patients with active disease or worsening symptoms.
Less frequent visits for patients with well-controlled symptoms.
Monitor symptoms, response to treatment, and potential complications.
Consider additional testing (e.g., Schirmer’s test) to monitor dry eye severity.
Refer to an ophthalmologist for severe dry eye complications or corneal damage.
Consider referral to a rheumatologist for complex cases or patients with significant joint involvement.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of Sjögren’s syndrome