Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for Chagas disease, evaluation of new symptoms, or initial diagnosis workup.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the reason for the visit. This may include:
For established diagnosis: New or worsening symptoms suggestive of acute or chronic Chagas disease:
Acute phase (within weeks to months of infection): fever, fatigue, muscle aches, headache, swollen lymph nodes, facial and eyelid swelling (periorbital edema).
Chronic phase (years to decades after infection): may be asymptomatic or have symptoms like fatigue, heartburn, constipation, abdominal pain, difficulty swallowing (megaesophagus), or bowel problems (megacolon).
Cardiac symptoms (if present): shortness of breath, chest pain, palpitations, fatigue, leg swelling (in later stages).
For suspected diagnosis: Exposure history to risk factors for Chagas disease (e.g., living in endemic area, history of blood transfusions in endemic area, history of consuming contaminated food or drink).
Past Medical History:
Briefly summarize relevant past medical history, including:
Underlying medical conditions
Previous diagnoses potentially related to Chagas disease (e.g., unexplained cardiomyopathy, unexplained gastrointestinal symptoms)
Social History:
Briefly inquire about risk factors for Chagas disease exposure (e.g., living in or travel to endemic areas, occupation with potential exposure to triatomine bugs).
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Physical Exam:
Perform a focused physical exam to assess for:
Signs of acute infection (if applicable)
Cardiac symptoms (e.g., jugular venous distention, peripheral edema) suggestive of heart failure in chronic cases.
Abdominal exam for organomegaly (enlarged liver or spleen).
Laboratory Tests (if performed):
Briefly document results of relevant laboratory tests, including:
Complete blood count (CBC) for abnormalities suggestive of infection
Serologic tests for Trypanosoma cruzi antibodies (positive test suggests exposure but not necessarily active infection)
Blood cultures (if suspicion of acute infection)
ECG (electrocardiogram) to assess for heart rhythm abnormalities
Chest X-ray (if indicated) to assess for lung involvement
Assessment (A):
Chagas Disease Status:
Based on clinical presentation, exposure history, and laboratory findings, assess the likelihood of Chagas disease:
Established diagnosis
Suspected diagnosis requiring further testing
Unlikely diagnosis
Disease Stage (if applicable):
For established diagnosis, consider the disease stage:
Acute phase
Chronic indeterminate phase (asymptomatic or mild symptoms)
Chronic cardiac or digestive phase (more severe symptoms)
Plan (P):
Diagnostic Testing (if needed):
If Chagas disease is suspected but not confirmed, order additional testing as needed (e.g., PCR testing for parasite DNA, additional serologic tests).
Treatment (if indicated):
Discuss treatment options for confirmed Chagas disease with an infectious disease specialist. Treatment with antiparasitic medications (benznidazole or nifurtimox) might be considered for:
Acute infection
Chronic indeterminate phase in some cases (depending on specific factors)
There is no cure for chronic Chagas disease, but treatment can help control the parasite and potentially slow disease progression.
Cardiac Management (if indicated):
If Chagas cardiomyopathy is present, refer to a cardiologist for management of heart failure symptoms and heart function monitoring.
Symptom Management:
Address specific symptoms with appropriate medications (e.g., pain management, medications for gastrointestinal issues).
Patient Education:
Educate the patient about Chagas disease, transmission risks, importance of preventative measures (e.g., avoiding insect bites in endemic areas, proper food handling), and the importance of medication adherence (if applicable).
Follow-up:
Schedule follow-up visits to monitor for response to treatment, disease progression, and manage complications.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., infectious disease specialist, cardiologist)
Prognosis discussion based on the stage and severity of the disease