Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint: Briefly describe the patient’s main reason for this visit. This could include:
Respiratory symptoms (cough, fever, shortness of breath) – acute or chronic
Fatigue, weight loss, malaise
Chest pain (pleuritic – sharp pain with breathing)
New or worsening symptoms (if chronic histoplasmosis)
History of Present Illness:
Duration and severity of symptoms
Travel history to areas endemic for histoplasmosis (Ohio and Mississippi River valleys, Southeast US)
Exposure to risk factors (caves, soil with bird droppings, bat guano)
Occupation (increased risk for those exposed to soil or bats)
Prior diagnosis of histoplasmosis (if applicable)
Past Medical History:
Underlying lung conditions (COPD, asthma)
Immunosuppression (HIV/AIDS, medication use)
Medications (current and recent)
Family History:
History of histoplasmosis in family members
社会史 (shè huì shǐ) Social History:
Smoking history (increases risk and severity)
Physical Examination:
General appearance (illness, malnutrition)
Vital signs (fever, tachypnea – rapid breathing)
Respiratory exam:
Chest auscultation (rales – crackling sounds)
Signs of pleural effusion (fluid around the lungs)
Lymph node exam (swollen lymph nodes)
Laboratory Tests:
Complete blood count (CBC) – may show anemia or elevated white blood cells
Electrolytes – to assess dehydration
Liver function tests – may be abnormal in disseminated histoplasmosis
Histoplasma antigen testing (urine or serum) – positive test suggests current or past infection
Histoplasma culture (sputum, blood, tissue) – definitive diagnosis but can take weeks
Imaging Studies:
Chest X-ray: may show infiltrates (areas of inflammation)
Chest CT scan: provides more detailed information about lung involvement
Diagnosis:
Presumptive histoplasmosis (based on clinical presentation and positive antigen test)
Confirmed histoplasmosis (positive culture)
Disseminated histoplasmosis (if spread beyond the lungs)
Treatment Plan:
Antifungal medication (itraconazole, amphotericin B) – duration depends on severity and immune status
Supportive care (oxygen therapy, pain management)
Surgery (rarely, for complications like lung abscess)
Prognosis:
Discuss the outlook based on severity and underlying health. Acute cases usually respond well to treatment.
Risk of chronic disease or reactivation in immunocompromised individuals.
Patient Education:
Explain histoplasmosis and the cause
Importance of completing the full course of antifungal medication
Avoiding future exposure to risk factors
Smoking cessation (if applicable)
Warning signs for worsening symptoms or relapse
Next Follow-up:
Schedule for the next appointment to monitor response to treatment, repeat testing, and address any ongoing symptoms.