Subjective
Date of visit
Reason for visit (initial presentation, follow-up for pilonidal disease)
History of present illness:
Location and chronicity of pilonidal sinus (new or recurrent)
Pain (severity, character – sharp, throbbing, constant)
Discharge (purulent drainage from the sinus)
Swelling or redness around the pilonidal area
History of previous surgeries for pilonidal disease (if applicable)
Past medical history (relevant conditions)
Medications (current medications)
Allergies
Objective
Vital signs (temperature, heart rate, blood pressure)
Physical exam:
General (signs of infection)
Perianal examination:
Inspection of the sacrococcyx area for pilonidal sinus opening(s)
Palpation for swelling, tenderness, or fluctuance (pus collection)
Assess for signs of inflammation (erythema – redness, induration – hardening)
Assess for secondary openings or sinus tracts
Assessment
Pilonidal disease (suspected based on history and physical exam findings)
Stage of pilonidal disease (acute abscess, chronic sinus, recurrent disease)
Presence of infection
Plan
Depending on the stage and severity:
Conservative management (for mild, non-infected cases):
Warm sitz baths
Pain medication (over-the-counter or prescription)
Antibiotics (if cellulitis is present)
Hair removal techniques (laser hair removal or shaving)
Surgical intervention:
Pilonidal sinus excision (removal of the sinus tract) with various closure techniques (primary closure, flaps) – definitive treatment for chronic or recurrent pilonidal disease
Wound care instructions (depending on the chosen treatment)
Education
Explain the diagnosis, stages of pilonidal disease, and treatment options
Importance of good hygiene in the pilonidal area
Discuss hair removal techniques to help prevent recurrence
Follow-up
Schedule for next appointment:
Monitor response to treatment (improvement of pain, drainage, healing)
Wound care management (if surgical intervention was performed)
Consider referral to a general surgeon for complex cases or recurrent pilonidal disease
Note: This template is a guide and may need to be modified based on the individual patient’s presentation, severity of pilonidal disease, and presence of complications.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of pilonidal disease.