Glomerulonephritis/Vasculitis Evaluation Note (Pediatric)

Date/Time of Service: [Date and time]

Location: [Clinic / Inpatient unit / ED / Telehealth]

Encounter Type: [New / Return / Consult]

Referring Clinician: [Name, specialty, contact]

Reason for Consult/Referral: [Brief reason]

Patient Name: [Full name]

MRN: [Medical record number]

DOB: [MM/DD/YYYY]

Age: [Age in years and months]

Sex: [Male / Female / Other]

Weight/Height/BSA: [Weight with units], [Height with units], [BSA]

Allergies: [Allergen(s) and reaction type/severity, or NKDA]

Guardian Present: [Name and relationship] (If not present, document who provided history)

Interpreter: [Language and modality / Not used]

Clinical Snapshot

[One-sentence problem representation: "[Age]-year-old [sex] with [relevant past medical history], presenting with [nephritic features], and [key systemic features], with [severity markers], concerning for [syndromic impression]."]

Immediate Risk Flags: [List any present: rapidly rising creatinine/oliguria, severe or symptomatic hypertension, pulmonary symptoms, nephrotic-range proteinuria, macroscopic hematuria with clots, thrombosis concern, immunosuppression already initiated elsewhere] (Include only flags that are present; omit this line if none)

Chief Complaint

[Chief complaint in patient/guardian words]

History of Present Illness

[Narrative timeline of nephritic features: hematuria onset and character, urine output changes, edema distribution and progression, hypertension timing and symptoms, baseline versus current renal function] (Anchor events to dates; if baseline creatinine unknown, state explicitly)

[Preceding triggers: recent infections with timing, antibiotic or NSAID use, new medications, travel or exposures]

[Systemic vasculitis/autoimmune symptom screen] (Document each as present or absent: palpable purpura with distribution, arthralgia/arthritis, abdominal pain or GI bleeding, sinusitis/epistaxis/cough/hemoptysis, fever/weight loss/fatigue, SLE features including photosensitivity/malar rash/oral ulcers/alopecia/Raynaud/serositis)

[Prior renal history: previous hematuria/proteinuria episodes, known renal anomalies, prior GN]

[Outside evaluation and treatments: prior labs with dates, imaging, steroids or immunosuppression started elsewhere with doses and start dates, prior hospitalizations]

Review of Systems

(Document pertinent positives and negatives only)

• General: [Fever / weight loss / fatigue]
• ENT/Pulmonary: [Sinus symptoms / cough / hemoptysis / dyspnea]
• Cardiovascular: [Chest pain / palpitations]
• GI: [Abdominal pain / nausea / vomiting / diarrhea / bleeding]
• GU: [Dysuria / frequency / flank pain / urine color changes]
• Skin: [Purpura / rash and distribution]
• Musculoskeletal: [Arthralgia / arthritis]
• Neurologic: [Headache / vision changes / seizure]
• Hematologic: [Easy bruising / bleeding]

Past History

• Past Medical/Surgical History: [Renal disease, autoimmune conditions, hypertension, prior vasculitis, surgeries]
• Medications: [Name, dose, route, frequency, indication; start date for new meds] (Flag nephrotoxins and immunosuppressants; note adherence and recent changes)
• Allergies: [Allergen, reaction type, severity]
• Family History: [Kidney disease, hematuria, hearing loss, autoimmune disease, thrombosis]
• Social History: [Living situation, caregivers, school, sports, dietary factors, adherence barriers] (For adolescents, document substance use and sexual activity only if relevant to teratogenic medication counseling)
• Immunizations/Infection History: [Routine vaccines status], [Varicella immunity], [TB risk and testing], [HBV/HCV/HIV status] (Include when immunosuppression is being considered)

Objective

Vitals: BP [value with cuff size and percentile if available; repeat confirmation if elevated], HR [value], RR [value], Temp [value], SpO2 [value], Height [value], Weight [value], BMI [percentile] (Include timestamps; if inpatient, include I/O summary and weight trend)

Physical Exam: [Pertinent positives and negatives: general appearance, HEENT (periorbital edema, oral/nasal ulcers), cardiovascular (perfusion, murmurs, edema), respiratory (work of breathing, crackles), abdomen (tenderness, organomegaly), skin (purpura morphology and distribution, edema), musculoskeletal (arthritis), neurologic (mental status, focal deficits, hypertensive emergency signs)] (If telehealth or limited exam, state limitations explicitly)

Point-of-Care Findings: [Urine dipstick results], [Urine microscopy: RBC morphology, RBC casts, other casts], [Fundoscopic exam findings if performed]

Laboratory Data

(Include specimen dates and source facility; show trends as baseline → peak → current)

• Renal Function Panel: [Creatinine trend], [BUN], [Electrolytes], [Bicarbonate], [Albumin]
• Urinary Studies: [Urinalysis with microscopy], [Urine protein quantification with method]
• Complement/Inflammatory: [C3], [C4], [CBC], [CRP/ESR if obtained]
• Serologies Resulted: [ANA], [anti-dsDNA], [ANCA PR3/MPO], [anti-GBM], [Streptococcal serologies], [HBV panel], [HCV Ab], [HIV], [Serum IgA], [Others as relevant] (Include values and dates)
• Pending: [Tests pending with order dates and expected turnaround]
• To Be Ordered: [Planned tests with brief rationale]

Imaging

• Renal Ultrasound: [Kidney size, echogenicity, cortical thickness, Doppler findings, obstruction, incidental findings] (Include date and facility)
• Chest Imaging: [CXR/CT findings] (Include only if pulmonary symptoms present)

Pathology

• Prior Kidney Biopsy: [Diagnosis/class, activity/chronicity indices, crescents %, fibrosis/atrophy, immune deposits, IF/EM summary] (Include if available)
• Biopsy Status: [Completed / Planned / Deferred / Not indicated]

Assessment

[Synthesis paragraph: Define the syndrome, leading diagnostic categories with supporting features (timing, complement pattern, proteinuria degree, systemic findings), and current severity/acuity. Label as clinical impression; do not assert unconfirmed diagnoses.]

• Nephritic Presentation/Suspected GN: [Clinical impression with key supporting data and differential]
• AKI or Reduced GFR: [Stage/severity and trend; state if baseline unknown]
• Hypertension: [Severity, symptom status, confirmation method]
• Proteinuria: [Quantification and trend]
• Hematuria: [Gross vs microscopic; associated symptoms]
• Edema/Volume Status: [Hypervolemia vs euvolemia; clinical signs]

(Add conditional problems only if applicable: Suspected IgA vasculitis nephritis, Suspected lupus nephritis, Suspected ANCA-associated vasculitis, Immunosuppression planning)

Plan

Nephritic Syndrome / Suspected GN

• Status: [Current severity: creatinine trend, BP range, protein/Cr, C3/C4]
• Differential: [Prioritized list with brief reasoning]
• Diagnostics: [Serologies and urine studies to repeat/obtain; criteria and timing for biopsy consideration]
• Therapeutics: [Supportive care, nephrotoxin avoidance, sodium restriction; immunosuppression if initiated]
• Monitoring: [UA/protein quantification cadence, renal function frequency, BP monitoring schedule]
• Escalation Triggers: [Rapid creatinine rise/oliguria, severe/symptomatic hypertension, pulmonary symptoms, worsening proteinuria]
• Disposition: [Inpatient vs outpatient; level of care; consults needed]

AKI / Reduced GFR

• Contributors: [Suspected prerenal/intrinsic/postrenal factors]
• Volume/Fluids: [Rationale for fluids vs diuresis; targets]
• Electrolytes: [Monitoring frequency and intervention thresholds]
• Medication Adjustments: [Dose adjustments/holds for renally cleared or nephrotoxic agents]

Hypertension

• Confirmation: [Repeat manual BP, appropriate cuff; ambulatory/home BP if indicated]
• Acute Management: [Agents, doses, route; monitoring] (If symptomatic or severe)
• Chronic Plan: [First-line agent(s) with dosing; home BP education and targets]

Proteinuria

• Current Status: [uPCR/uACR values and trend]
• Follow-up Testing: [Repeat quantification plan and timing]
• RAAS Blockade: [Initiated / Considered / Contraindicated with reasoning]

Hematuria

• Character: [Gross vs microscopic; clots; timing]
• Monitoring: [Return precautions; activity guidance if gross hematuria]

Edema / Volume

• Diet/Fluids: [Sodium and fluid guidance]
• Diuretics: [Agent, dose, frequency; response monitoring]

Suspected IgA Vasculitis Nephritis

(Include only when palpable purpura or classic systemic features are present)

• Extrarenal Involvement: [Skin severity/morphology, joints, GI manifestations]
• Renal Monitoring: [UA, protein quantification, BP, creatinine at specified intervals]
• Escalation Thresholds: [Increasing proteinuria, worsening renal function, persistent hypertension]
• Coordination: [Rheumatology involvement and shared plan]

Suspected Lupus Nephritis Workup

(Include only when SLE is known or suspected)

• Workup: [Serologies, complements, urine protein quantification, biopsy evaluation planning]
• Multidisciplinary: [Rheumatology and pathology coordination]
• Counseling: [Clinical findings may not predict histologic class; biopsy guides therapy]

Suspected ANCA-Associated Vasculitis

(Include only when ENT/pulmonary symptoms, rapidly progressive course, or high clinical suspicion)

• Urgent Evaluation: [ANCA testing, chest imaging, renal function trend, urinalysis, biopsy discussion, pulmonary evaluation]
• Escalation Triggers: [Hemoptysis, hypoxia, rapidly rising creatinine, systemic deterioration]

Kidney Biopsy Planning

(Include only when biopsy is planned or actively discussed)

• Indication: [Tied to objective findings: proteinuria threshold, rising creatinine, active sediment, suspected diagnosis requiring tissue]
• Risks/Benefits Discussed: [Bleeding, sedation/anesthesia, transfusion possibility, diagnostic and therapeutic impact]
• Family Understanding: [Questions addressed; understanding confirmed]
• Pre-Biopsy Logistics: [Labs per protocol, BP control plan, timing, admission plan, NPO instructions]
• Status: [Proceeding / Deferred with reason]

Immunosuppression Counseling

(Include only when immunosuppression is discussed, initiated, or anticipated)

• Infection Risk Counseling: [Plain-language discussion; understanding confirmed]
• Screening Completed/Planned: [TB assessment/testing], [HBV/HCV/HIV], [Varicella immunity]
• Prophylaxis: [PJP prophylaxis: recommended / deferred / not indicated with reasoning]
• Vaccinations: [Status review; timing relative to immunosuppression; live vaccine considerations; coordination plan]
• Reproductive Counseling: [Pregnancy testing], [Contraception counseling], [Fertility preservation if relevant] (For adolescents when teratogenic therapy is considered)
• Toxicity Monitoring: [Agent-specific baseline and follow-up labs; adverse effects discussed; monitoring intervals]
• Shared Decision-Making: [Benefits, risks, alternatives discussed; guardian consent and patient assent documented; questions answered]

Care Coordination

• Specialty Coordination: [Rheumatology / Pathology / Infectious Disease / Social Work / Dietitian with contact date/time and agreed plan]
• Referring Clinician Communication: [Summary of discussion; date/time and method]

Follow-Up Plan

• Follow-up Interval: [Clinic/telehealth/inpatient reassessment timing]
• Pending Items: [Labs/studies pending; who will review; expected turnaround]
• Next Milestones: [Biopsy date, specialty visits, monitoring labs]
• Contingency Plan: [Instructions if labs worsen or symptoms escalate; contact information]