Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of MCTD-associated ILD. Reports progressive exertional dyspnea (mMRC grade [X]), non-productive cough, and fatigue. Denies orthopnea, PND, or chest pain. Symptoms stable/worsening since last visit. Current RNP antibody status confirmed. No recent exacerbation of systemic features (Raynaud’s, inflammatory arthritis, or sclerodactyly).
Clinical Examination Findings
General: Patient in no acute distress, resting comfortably. Respiratory: Bilateral fine end-inspiratory bibasilar crackles (Velcro-like) on auscultation. No wheezing or rhonchi. Cardiovascular: Regular rate and rhythm, S1/S2 normal, no murmurs or S3/S4. Extremities: No peripheral edema, clubbing, or cyanosis. Skin: Evidence of sclerodactyly and periungual telangiectasia noted.
Treatment Protocol
Plan: Continue current immunosuppressive therapy ([Drug/Dose]). Monitor pulmonary function tests (PFTs) and DLCO every 3-6 months. High-resolution CT (HRCT) chest scheduled for [Date] to assess ILD progression. Optimize management of Raynaud’s phenomenon with CCBs. Smoking cessation counseling provided. Influenza and pneumococcal vaccinations updated.