Patient: [Patient Name]
Date: [Date of Encounter]
I. History of Present Illness:
Date of symptom onset:
Presenting symptoms (select all that apply):
Fever
Cough (productive or non-productive)
Chest pain (pleuritic or non-pleuritic)
Fatigue
Night sweats
Weight loss
Skin lesions (erythema nodosum)
Joint pain
Difficulty breathing (severe cases)
Travel history to endemic areas (Southwest US, Mexico, Central and South America) within the past year: (yes/no)
Occupation or hobbies with potential for exposure (e.g., construction, excavation):
Risk factors for severe disease (immunocompromised, pregnant, extremes of age)
Prior diagnosis of coccidioidomycosis: (yes/no)
II. Past Medical History:
Underlying medical conditions (diabetes, HIV, malignancy)
Immunosuppressive medications: (current or recent use)
III. Social History:
Smoking history: (current smoker, former smoker, never smoker)
Dust exposure (occupational or environmental)
IV. Physical Exam:
Vital signs: (BP, HR, RR, Temp)
Respiratory exam: (rales, wheezing, tachypnea)
Skin exam: (erythema nodosum lesions)
Lymph node exam: (lymphadenopathy)
V. Assessment:
Suspected/confirmed coccidioidomycosis (based on clinical presentation, travel history, and diagnostic tests)
Disease severity (pulmonary, disseminated)
Risk factors for complications
VI. Diagnostic Studies:
Chest X-ray: (infiltrates, nodules, cavities)
Sputum culture (if productive cough):
Positive culture for Coccidioides immitis
Serological tests:
Complement fixation (CF) antibody titers: IgG and IgM
Enzyme-linked immunosorbent assay (ELISA) for antibodies
Other tests (if indicated):
Bronchoscopy with bronchoalveolar lavage (BAL)
Gallium scan
Imaging studies (CT scan) for complications
VII. Plan:
Treatment plan:
Antifungal medications (fluconazole, itraconazole, voriconazole) – type, dose, and duration
Supportive care (fever control, pain management, respiratory support)
Monitoring plan: (clinical follow-up, laboratory tests, imaging studies)
Education: Patient education on coccidioidomycosis, treatment plan, potential side effects, and importance of adherence.
VIII. Notes:
Include any additional relevant information, such as response to treatment, complications, or need for specialist consultation.
IX. Resources:
Consider providing patient education materials on coccidioidomycosis from reputable sources (e.g., Centers for Disease Control and Prevention (CDC), American Lung Association).