Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of systemic sclerosis (M34.9). Reports progressive skin thickening involving [fingers/hands/face], accompanied by Raynaud’s phenomenon characterized by triphasic color changes in response to cold. Denies new onset dyspnea, dysphagia, or significant joint pain. Current symptoms include [e.g., digital ulcers, GERD, fatigue].
Clinical Examination Findings
General: Patient appears [well/chronically ill]. Skin: Sclerodactyly noted with loss of normal skin folds, taut skin over dorsal hands, and perioral furrowing. Telangiectasias present on [face/palms]. Musculoskeletal: Reduced range of motion in [fingers/wrists]. Cardiovascular: S1/S2 regular, no murmurs. Pulmonary: Lungs clear to auscultation bilaterally. Extremities: No active digital ulcers; capillary refill < 2 seconds.
Treatment Protocol
Plan: 1. Continue current immunosuppressive therapy: [Medication/Dose]. 2. Manage Raynaud’s with Calcium Channel Blockers (e.g., Nifedipine). 3. GERD management with PPIs. 4. Regular monitoring of PFTs and Echo for pulmonary hypertension/interstitial lung disease. 5. Wound care for digital ulcers as needed.