Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Evaluation of suspected chancroid, follow-up for diagnosed chancroid, or evaluation of genital ulcer.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the following:
Onset and duration of genital ulcer(s)
Location, size, number, and appearance of the ulcer(s) (e.g., painful, tender, irregular borders)
Associated symptoms (e.g., inguinal lymphadenopathy – swollen lymph nodes in the groin, purulent discharge from the ulcer)
Sexual history (number of sexual partners, unprotected sex)
Recent travel to endemic areas
Past Medical History:
Briefly summarize relevant past medical history, including:
Previous sexually transmitted infections (STIs)
Allergies to medications
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Genital Exam:
Perform a thorough genital exam to assess:
Location, size, number, and appearance of the ulcer(s)
Presence of purulent discharge
Inguinal lymphadenopathy (unilateral or bilateral) – swollen, tender lymph nodes in the groin
Laboratory Tests (if performed):
Briefly document the results of relevant laboratory tests, including:
Gram stain and culture of the ulcer exudate to identify Haemophilus ducreyi, the causative bacteria for chancroid.
Serologic tests for other STIs (e.g., syphilis, gonorrhea, HIV) are often recommended due to the possibility of coinfection.
Assessment (A):
Differential Diagnosis:
Consider other causes of genital ulcers in the differential diagnosis, such as:
Herpes simplex virus (HSV)
Syphilis
Behçet’s disease
Diagnosis:
Based on clinical presentation, laboratory test results, and sexual history, diagnose suspected chancroid, confirmed chancroid, or another cause of the genital ulcer.
Plan (P):
Treatment:
If chancroid is confirmed, initiate antibiotic treatment with a single dose of azithromycin or ceftriaxone injection. Consider alternative antibiotics for patients with allergies.
Advise sexual partners to be evaluated and treated for chancroid.
Follow-up:
Schedule a follow-up visit in 7-14 days to assess treatment response and healing of the ulcer(s).
Emphasize the importance of completing the antibiotic regimen and avoiding sexual contact until the ulcers are completely healed.
Patient Education:
Educate the patient about chancroid, transmission risks, importance of safe sexual practices, and the need to inform sexual partners.
Discuss the possibility of coinfection with other STIs and the importance of testing.
Advise on proper hygiene practices to prevent further complications.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., infectious disease specialist) if needed.
Referral for partner notification services.
Importance of safe sex practices to prevent future STIs.