Patient: [Patient Name]
Date: [Date of Encounter]
I. Chief Complaint:
Skin lesions (describe location, number, size, appearance – ulcerated, papules, nodules)
Mucosal involvement (if present – nasal congestion, epistaxis, facial disfigurement)
Fever (may or may not be present)
Fatigue
Lymphadenopathy (swollen lymph nodes) – may be present
II. History of Present Illness:
Onset and duration of skin lesions
Progression of lesions (growth, changes in appearance)
Travel history to endemic areas (important for diagnosis)
Previous exposure to individuals with leishmaniasis
III. Past Medical History:
Underlying medical conditions (HIV/AIDS weakens immune system and increases risk)
Previous travel to endemic areas
IV. Medications:
Current medications
V. Social History:
Occupation (outdoor activities may increase exposure risk)
Travel history (including details of travel to endemic areas)
VI. Physical Exam:
Vital signs (BP, HR, RR, Temp)
Skin exam:
Location, number, and size of skin lesions
Characteristics of lesions (ulcerated, papules, nodules, crusted)
Regional lymphadenopathy
Mucosal exam (if applicable):
Nasal mucosa (septal perforation, ulceration)
Oropharyngeal mucosa
VII. Diagnostic Studies (consider as appropriate):
Microscopy:
Direct smear or Giemsa stain of lesion material – may show amastigotes (parasite form)
Skin biopsy with histopathology and parasite identification (gold standard for diagnosis)
Serologic tests:
Enzyme-linked immunosorbent assay (ELISA) – may not be diagnostic but can support diagnosis
Indirect fluorescent antibody test (IFAT) – similar to ELISA
Molecular tests (PCR):
Polymerase chain reaction (PCR) – highly specific for Leishmania species identification
VIII. Assessment:
Suspected cutaneous or mucocutaneous leishmaniasis based on clinical presentation, travel history, and characteristic skin lesions.
Confirmation of diagnosis pending results of diagnostic tests (microscopy, serology, or PCR).
Species identification of Leishmania parasite (helpful for treatment decisions).
IX. Plan:
Treatment depends on the Leishmania species, severity of lesions, and presence of mucosal involvement.
Antiparasitic medications (e.g., pentamidine, sodium stibogluconate, amphotericin B) – typically long treatment courses are needed.
Local wound care for skin lesions
Referral to an infectious disease specialist may be indicated for complex cases.
X. Prognosis:
Discuss the potential for cure with appropriate treatment, although some scarring may persist.
Adherence to medication regimen is crucial for successful treatment.
For mucocutaneous leishmaniasis, the prognosis depends on the extent of mucosal involvement and prompt treatment.
XI. Notes:
Include any additional observations or concerns, such as patient’s understanding of the diagnosis and treatment plan, potential side effects of medications, need for follow-up appointments, and preventive measures to avoid future infection.
XII. Resources:
Consider providing patient education materials on cutaneous and mucocutaneous leishmaniasis from reputable sources (e.g., Centers for Disease Control and Prevention (CDC), World Health Organization (WHO)).