Patient: [Patient Name]
Date: [Date of Encounter]
I. Chief Complaint:
Headache (severity, location, duration)
Fever (temperature)
Neck stiffness (meningismus)
Altered mental status (confusion, lethargy, disorientation)
Nausea or vomiting
Photophobia (sensitivity to light) – may be present
II. History of Present Illness:
Onset and duration of symptoms
Progression of symptoms (worsening, improvement)
Risk factors for cryptococcal meningitis (immunosuppression – HIV/AIDS, organ transplantation, high-dose corticosteroids)
Previous travel history (fungus more common in some regions)
III. Past Medical History:
Underlying medical conditions (HIV/AIDS, malignancy, other immunosuppressive conditions)
Previous central nervous system (CNS) infections
IV. Medications:
Current medications (antiretroviral therapy for HIV, immunosuppressants, antifungals if started)
V. Social History:
Recent travel history (relevant for some geographic areas)
VI. Vital Signs:
Blood pressure (BP)
Heart rate (HR)
Respiratory rate (RR)
Temperature (Temp)
VII. Physical Exam:
General appearance (illness severity, signs of meningeal irritation)
Neurologic exam:
Mental status (alertness, orientation)
Cranial nerve palsies (may occur)
Neck stiffness (Brudzinski sign and Kernig sign)
Fundoscopic exam (papilledema may be present)
VIII. Laboratory Studies:
Cerebrospinal fluid (CSF) analysis:
Opening pressure (elevated in most cases)
Cell count (lymphocytic pleocytosis)
Protein (elevated)
Glucose (decreased)
Cryptococcal antigen (positive test confirms diagnosis)
Blood tests:
HIV testing (if not already known)
Complete blood count (CBC)
Electrolytes
IX. Imaging Studies (consider as appropriate):
Head CT scan (may be normal or show signs of increased intracranial pressure)
MRI scan (may be more sensitive for detecting fungal lesions)
X. Assessment:
Confirmed or suspected cryptococcal meningitis based on clinical presentation, risk factors, and CSF analysis (positive cryptococcal antigen).
Severity of illness (consider level of mental status alteration, meningeal signs)
Underlying cause of immunosuppression (most commonly HIV/AIDS)
XI. Plan:
Antifungal therapy: Prompt initiation of antifungal medications with amphotericin B followed by fluconazole is crucial.
Management of underlying immunosuppression (e.g., antiretroviral therapy for HIV)
Supportive care (pain management, fluids, electrolytes)
Intracranial pressure management (if needed)
Repeat CSF analysis to monitor response to treatment
XII. Prognosis:
Discuss the seriousness of cryptococcal meningitis but also the potential for improvement with early diagnosis and treatment.
Prognosis depends on the severity of illness, immune status, and response to antifungal therapy.
XIII. Notes:
Include any additional observations or concerns, such as patient’s understanding of the diagnosis and treatment plan, potential side effects of medications, need for infectious disease consultation, and social support services.
XIV. Resources:
Consider providing patient education materials on cryptococcal meningitis from reputable sources (e.g., Centers for Disease Control and Prevention (CDC), Infectious Diseases Society of America (IDSA)).