Nephrotic Syndrome Visit Note (Pediatrics)

Date: [date]

Location: [clinic / hospital / telehealth]

Patient: [name, age, current weight]

Visit Type: [new-onset evaluation / relapse / remission follow-up / medication monitoring / post-hospital follow-up]

Information Sources: [patient / parent–caregiver / home dipstick log / outside records]

Chief Complaint

[One-line statement of presenting concern] (May include a brief direct quote if helpful.)

History of Present Illness

(Provide a concise, chronological narrative beginning with the chief complaint. Integrate relevant past history only if it directly impacts today's assessment.)

• Episode classification: [suspected new-onset / confirmed nephrotic syndrome / relapse—suspected / relapse—confirmed / remission follow-up] (Explicitly state status and criteria used: home dipstick trend, clinic UA/UPCR, presence/absence of edema, albumin if available.)
• Edema and volume-status symptoms: [location and severity of edema, symptoms of intravascular depletion if present] (Specify onset, duration, and current severity.)
• Home monitoring data: [urine dipstick results with dates, daily weights, home blood pressures if available] (Explicitly note if no home log is available.)
• Infection risk screen: [fever, ill contacts, respiratory or skin symptoms, abdominal pain, immunization status] (If immunization or varicella immune status is unknown, state [Unknown—must be obtained].)
• Thrombosis symptom screen: [limb swelling/pain, chest pain, dyspnea, headache, flank pain, gross hematuria as relevant]
• Steroid and immunosuppression history: [date of initial diagnosis, phenotype, current steroid dose and taper plan, relapse history with triggers, cumulative steroid burden and toxicity symptoms, other immunosuppressants with doses and adherence] (If current steroid dose is unknown, state [Unknown—must be obtained].)

Red flags for new-onset/atypical presentations: [gross hematuria, persistent microscopic hematuria, sustained hypertension, low complement, AKI not attributable to hypovolemia, systemic symptoms, age <1 year or >12 years] (Include only if relevant to this visit.)

Pertinent history and medications: [prior nephrotic episodes, AKI, relevant comorbidities, current medications with doses, allergies with reaction type, targeted family history] (If allergies are unknown, state [Allergy history unknown—must be obtained].)

Objective

• Vitals: [weight with comparison to baseline/dry weight, height, BP with percentile, HR, RR, temp, SpO2]
• Exam: [general appearance and hydration markers, edema assessment with location and severity, lungs, abdomen including ascites assessment, skin, extremities, neurologic if thrombosis concern] (Document if exam is limited and why.)
• Volume Status Assessment: [euvolemic / intravascularly depleted / volume overloaded] (State conclusion explicitly with supporting clinical findings.)
• Urine: [dipstick protein/blood, UPCR if obtained, microscopy if available]
• Labs: [albumin, creatinine, electrolytes, CBC, drug levels as applicable]
• Imaging/Other: [studies obtained or reviewed] (Include only if performed.)

Assessment

(Problem-list format ordered by clinical priority.)

• Nephrotic syndrome status: [in remission / partial remission / relapse—suspected / relapse—confirmed / steroid-resistant / pending response] (State criteria used and response phenotype if known: steroid-sensitive, frequently relapsing, steroid-dependent, steroid-resistant. Note high-risk features if present.)
• [Additional active problems: edema/volume status, hypertension, AKI, infection concern, medication toxicity as applicable]

Plan

• Nephrotic syndrome treatment:
  • [Steroid regimen: dose, schedule, taper plan, and criteria defining response]
  • [Steroid-sparing therapy if applicable: indication, agent, dose]
  • [Contingency plan if no remission by defined timepoint]
• Edema/volume management:
  • [Volume assessment conclusion tied to management decisions]
  • [Sodium guidance; fluid restriction only if indicated with rationale]
  • [Diuretic plan if used; albumin infusion criteria if relevant]
• Infection prevention:
  • [Fever action plan with threshold for same-day evaluation]
  • [Immunization plan including pneumococcal catch-up and live vaccine precautions]
  • [Varicella exposure plan with immune status and prophylaxis pathway] (If varicella immune status is unknown, state [Unknown—must be obtained].)
• Thrombosis prevention:
  • [Risk assessment summary, non-pharmacologic measures]
  • [Prophylactic anticoagulation: indicated / not indicated with justification]
• Steroid toxicity monitoring:
  • [Growth/BMI tracking, mood/sleep, glucose if indicated, bone health with calcium/vitamin D plan, eye monitoring schedule for prolonged courses]
• Biopsy/genetic testing (Include only if clinically relevant):
  • [Indications present, decision made, counseling provided]
• Patient/family education:
  • [Home dipstick instructions with frequency and callback threshold]
  • [Weight/BP monitoring instructions, diet guidance]
  • [Red flag symptoms with exact escalation path: call clinic vs ED]
• Follow-up:
  • [Follow-up interval, labs to obtain before next visit, coordination with PCP or specialists]