Date: [Date of encounter]
Patient: [Patient Name]
Chief Complaint:
Document the patient’s main concerns related to systemic sclerosis (SSc), such as joint pain, stiffness, skin thickening, fatigue, or new symptoms.
History of Present Illness:
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 SSc and response to treatment.
Recent infections or exposures that could trigger a flare.
Past Medical History:
Date of SSc diagnosis and specific subtype (limited cutaneous vs. diffuse cutaneous).
Prior SSc manifestations (e.g., Raynaud’s phenomenon, interstitial lung disease, gastrointestinal involvement).
Past hospitalizations or surgeries related to SSc.
Comorbid medical conditions (e.g., pulmonary hypertension, renal disease).
Medications:
List all current medications, including those for SSc and any other conditions.
Document medication adherence and any side effects.
Social History:
Smoking history (smoking can worsen SSc symptoms).
Occupational exposures (e.g., silica dust) that may have contributed to SSc.
Family History:
Presence of autoimmune diseases in first-degree relatives.
Physical Exam:
Vital signs (e.g., elevated blood pressure may indicate pulmonary hypertension).
General examination (e.g., weight loss, skin thickening, puffy hands).
Musculoskeletal examination (joint pain, tenderness, limited range of motion).
Skin examination (extent and characteristics of skin thickening, telanangiectasia).
Respiratory examination (rales on auscultation may indicate interstitial lung disease).
Cardiovascular examination (murmurs suggestive of pulmonary hypertension).
Laboratory Tests (as indicated):
Complete blood count (CBC) to assess for anemia or infection.
Electrolytes and kidney function tests to monitor for organ involvement.
Liver function tests.
Antinuclear antibody (ANA) titer and specific autoantibodies (e.g., anti-centromere) to confirm diagnosis and monitor disease activity.
Inflammatory markers (e.g., C-reactive protein, erythrocyte sedimentation rate) to assess disease activity.
Urinalysis to assess for proteinuria.
Pulmonary function tests (PFTs) to evaluate lung function.
Echocardiogram to assess for pulmonary hypertension (if indicated).
Other tests as needed (e.g., chest X-ray, GI imaging for suspected 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 SSc (e.g., interstitial lung disease, pulmonary hypertension, gastrointestinal involvement, renal crisis).
Plan:
Treatment Adjustments: Modify medications as needed to control disease activity.
Consider adding or adjusting immunosuppressive medications, vasodilators for Raynaud’s phenomenon, antifibrotic medications, or other targeted therapies.
Management of Specific Manifestations: Address individual symptoms like joint pain, fatigue, skin tightness, or gastrointestinal issues.
Patient Education: Educate the patient about SSc, triggers, medications, self-management strategies (e.g., skin care, physical therapy).
Referral: Consider referral to a rheumatologist for specialized care if needed, or to other specialists (e.g., pulmonologist, cardiologist, gastroenterologist) depending on the affected organ systems.
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 SSc