Date: [Date of encounter]
Patient: [Patient Name]
Chief Complaint:
Document the patient’s main concerns related to Takayasu arteritis, such as new or worsening symptoms (e.g., weakness, claudication, dizziness, vision changes, headaches).
History of Present Illness:
Onset and duration of symptoms.
Progression of symptoms over time.
Specific location and characteristics of symptoms (e.g., unilateral or bilateral arm weakness, claudication in legs, bruits over affected arteries).
History of blood pressure discrepancies in different limbs.
Previous evaluations or treatments for suspected Takayasu arteritis.
Past Medical History:
Underlying medical conditions (e.g., hypertension, hyperlipidemia)
History of other autoimmune diseases
Surgical history (vascular procedures)
Family History:
Family history of Takayasu arteritis or other autoimmune diseases
Social History:
Tobacco use (smoking is a risk factor for Takayasu arteritis)
Physical Exam:
Vital signs (measure blood pressure in both arms to assess for discrepancies)
General examination (assess for signs of inflammation, weight loss)
Cardiovascular examination:
Palpation of peripheral pulses (weak or absent pulses in affected arteries)
Auscultation for bruits over major vessels
Blood pressure measurement in both arms (discrepancies suggestive of Takayasu arteritis)
Neurological examination (if neurological symptoms are present)
Laboratory Tests:
C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) – elevated levels may indicate inflammation
Antineutrophil cytoplasmic antibodies (ANCA) – may be positive in some patients with Takayasu arteritis
Lipid panel
Imaging Studies:
Angiography (traditional angiography or MRA) – definitive test to visualize narrowing or occlusion of arteries
Doppler ultrasound – may detect blood flow abnormalities and assess severity of arterial narrowing
Assessment:
Clinical suspicion of Takayasu arteritis based on symptoms and physical exam findings.
Presence of any confirmatory evidence from imaging studies.
Disease activity based on laboratory markers (CRP, ESR).
Involved arteries and severity of stenosis/occlusion based on imaging.
Presence of any complications (e.g., aneurysm formation, limb ischemia).
Plan:
Treatment: Discuss treatment options based on disease activity and severity. This may include medications (corticosteroids, immunosuppressants), vascular interventions (balloon angioplasty, stenting), or surgery (bypass grafts).
Monitoring: Schedule regular follow-up appointments to monitor disease activity, assess response to treatment, and detect potential complications.
Repeat laboratory tests (CRP, ESR) and imaging studies (angiography or MRA) as needed.
Lifestyle Modifications: Encourage smoking cessation if applicable.
Patient Education: Educate the patient about Takayasu arteritis, treatment options, potential complications, and the importance of medication adherence and follow-up care.
Follow-up:
Schedule follow-up appointments based on disease activity and treatment plan.
Additional Notes:
Document any additional relevant information not covered above (e.g., patient education provided, referral to a rheumatologist or vascular specialist).
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 diagnosis, treatment, and management of Takayasu arteritis