Date: [Date of encounter]
Patient: [Patient Name]
Chief Complaint:
Document the patient’s main concerns related to SLE, such as joint pain, fatigue, rash, or new symptoms.
History of Present Illness:
Describe the current disease activity:
Flare-up (increased symptoms) vs. stable disease.
Duration and severity of current symptoms.
Any new symptoms or changes in existing ones.
Medications used for SLE and response to treatment.
Recent infections or exposures that could trigger a flare.
Past Medical History:
Date of SLE diagnosis and current classification criteria used.
Prior SLE manifestations (e.g., arthritis, skin involvement, renal involvement, neurological involvement).
Past hospitalizations or surgeries related to SLE.
Comorbid medical conditions (e.g., hypertension, osteoporosis).
Medications:
List all current medications, including those for SLE and any other conditions.
Document medication adherence and any side effects.
Social History:
Smoking history (smoking can worsen SLE symptoms).
Sun exposure habits (sun exposure can trigger flares).
Stress levels (stress can also trigger flares).
Family History:
Presence of autoimmune diseases in first-degree relatives.
Physical Exam:
Vital signs (e.g., fever may indicate infection or active SLE).
General examination (e.g., malar rash, butterfly rash, oral ulcers).
Musculoskeletal examination (joint tenderness, swelling, arthritis).
Skin examination (rash characteristics, photosensitivity).
Neurological examination (if neurological involvement is suspected).
Laboratory Tests (as indicated):
Complete blood count (CBC) to assess for anemia or infection.
Electrolytes and kidney function tests to monitor for organ involvement.
Urinalysis to assess for kidney involvement.
Anti-nuclear antibody (ANA) titer and specific autoantibodies (e.g., anti-dsDNA) to confirm diagnosis and monitor disease activity.
Inflammatory markers (e.g., C-reactive protein, erythrocyte sedimentation rate) to assess disease activity.
Other tests as needed (e.g., chest X-ray, imaging studies for specific organ involvement).
Assessment:
Disease activity (flare-up vs. stable disease) based on symptoms, physical exam, and labs.
Identification of potential triggers for the current flare-up (if applicable).
Response to current treatment regimen.
Evaluation for potential complications of SLE (e.g., kidney involvement, neurological involvement).
Plan:
Treatment Adjustments: Modify medications as needed to control disease activity.
Consider adding or adjusting immunosuppressive medications, corticosteroids, or other targeted therapies.
Management of Specific Manifestations: Address individual symptoms like joint pain, fatigue, or skin rash.
Patient Education: Educate the patient about SLE, triggers, medications, and self-management strategies.
Referral: Consider referral to a rheumatologist for specialized care if needed.
Follow-up:
Schedule follow-up appointments to monitor disease activity, adjust treatment plan, and screen for complications.
Advise the patient to contact their healthcare provider if they experience any new or worsening symptoms.
Additional Notes:
Document any additional relevant information not covered above (e.g., vaccination status).
Disclaimer: This template is for informational purposes only and should be adapted to fit the specific needs of each patient. It is important to follow established guidelines for the management of SLE.