Date:
Patient:
MRN:
Clincian: (Dermatologist, Infectious Disease Specialist)
Reason for Visit:
New diagnosis of granuloma inguinale (GI)
Follow-up for established GI
Evaluation of treatment response and potential complications
History of Present Illness:
Briefly describe the patient’s current status:
New Diagnosis:
Date of suspected exposure (if known)
Onset, duration, and characteristics of genital lesions (painless, beefy red nodules, ulcerations)
Presence of any associated symptoms (inguinal lymph node swelling, purulent discharge)
Established Diagnosis:
Duration of symptoms and response to previous treatment approaches (antibiotics)
Progression or improvement of lesions
Past Medical History:
Underlying medical conditions (HIV infection can worsen GI)
Immunosuppressive medications (can increase risk of severe GI)
Social History:
Sexual history (number of partners, condom use) is crucial for identifying potential transmission sources.
Physical Exam:
Skin and mucous membrane exam:
Focus on the anogenital region, looking for characteristic GI lesions (ulcerative plaques, vegetations) on the genitals, groin, or perianal area.
Assess for inguinal lymphadenopathy (swollen lymph nodes).
Labs:
Direct smear microscopy: Microscopic examination of Giemsa-stained smears from lesions looking for Donovan bodies (diagnostic inclusion bodies of the causative bacteria).
Consider mentioning other labs ordered as needed (bacterial cultures to rule out co-infections, HIV testing).
Assessment:
Summarize the diagnosis and disease stage:
Confirmation of GI diagnosis based on clinical presentation, microscopy results, and potential culture results (if performed).
Stage of the disease (early localized lesions or advanced involvement with lymphatic spread).
Plan:
Outline the treatment plan based on the assessment:
Antibiotic therapy: Azithromycin or tetracycline are the mainstay of treatment for GI.
Consider mentioning the importance of completing the full course of antibiotics even if symptoms improve.
Partner notification and treatment: Sexual partners should be evaluated and treated if necessary to prevent transmission.
Prognosis:
Briefly discuss the prognosis. Granuloma inguinale is a treatable bacterial infection. Early diagnosis and treatment with antibiotics can effectively cure the infection.
Emphasize the importance of completing treatment, avoiding re-exposure, and returning for follow-up to ensure complete eradication of the bacteria.
Education:
Document any education provided to the patient regarding:
The nature of granuloma inguinale, its symptoms, and transmission routes
The importance of safe sex practices and partner notification
The details of the antibiotic treatment regimen and potential side effects
The importance of completing treatment and avoiding re-exposure
The need for follow-up appointments to monitor treatment response
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about medication side effects, sexual health, or potential complications.
Consider the emotional well-being of the patient and offer support or referral for mental health services if needed.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a dermatologist or infectious disease specialist for diagnosis, treatment recommendations, and prognosis.