Date: [Date of encounter]
Patient: [Patient Name]
Chief Complaint:
Document the patient’s main concerns related to tinea capitis, such as:
Itchy scalp
Patchy hair loss (may describe as circular or scaling)
Redness, scaling, or crusting on the scalp
Tenderness to the touch (less common)
History of Present Illness:
Onset, duration, and progression of symptoms.
Location and size of the affected area(s) on the scalp.
Any recent history of sharing hats, combs, or other personal items with others.
Previous history of tinea capitis or other fungal infections.
Past Medical History:
Allergies (especially to medications).
Underlying medical conditions that may weaken the immune system (e.g., HIV, chronic illnesses).
Current medications (including topical steroids, which can mask symptoms).
Family History:
Family history of tinea capitis or other fungal infections.
Social History:
Recent travel or contact with individuals known to have tinea capitis.
Pet ownership (some pets can carry fungal infections transmissible to humans).
Physical Exam:
Vital signs (usually normal).
Scalp examination:
Look for areas of patchy hair loss with broken hairs.
Assess for erythema (redness), scaling, crusting, or pustules on the scalp.
Palpate the scalp for tenderness.
Examine hair shafts for signs of fungal invasion (e.g., “black dots” on broken hair shafts).
Diagnostic Tests (as indicated):
Wood’s lamp examination: Ultraviolet light can cause infected hair shafts to fluoresce a green color, aiding in diagnosis of certain types of tinea capitis.
Microscopic examination of hair samples: Scalp hair or plucked hair can be examined under a microscope with potassium hydroxide (KOH) to identify fungal elements.
Fungal culture (less common): May be used in some cases to identify the specific fungal species, especially if initial tests are inconclusive.
Assessment:
Clinical suspicion of tinea capitis based on history and physical exam findings.
Differentiation between different types of tinea capitis based on clinical presentation and potential diagnostic tests.
Consideration of potential complications (e.g., bacterial superinfection, scarring).
Plan:
Antifungal Treatment: Topical antifungal medications (e.g., clotrimazole, miconazole, terbinafine) are the mainstay of treatment for most cases of tinea capitis. Oral antifungal medications (e.g., griseofulvin, terbinafine) may be necessary for more severe or extensive cases.
Hygiene Measures:
Instruct the patient on proper hair hygiene practices to prevent spreading the infection (e.g., frequent shampooing, avoiding sharing personal items).
Consider cleaning hats, brushes, and combs used by the patient to prevent reinfection.
Follow-up: Schedule follow-up appointments to monitor treatment response and ensure complete resolution of the infection.
Patient Education:
Educate the patient about tinea capitis, its cause (fungal infection), and how it spreads.
Explain the importance of completing the full course of antifungal medication, even if symptoms improve.
Discuss hygiene measures to prevent spreading the infection to others.
Address any concerns about hair loss and reassure that hair typically grows back after successful treatment.
Disclaimer: This template is for informational purposes only and should be adapted to fit the specific needs of each patient. The diagnosis and treatment of tinea capitis require evaluation by a healthcare professional.