Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Visit:
New or worsening warts
Follow-up for wart treatment
II. History of Present Illness:
New wart:
Location and number of warts
Appearance (common, plantar, flat)
Duration
Any associated symptoms (pain, discomfort)
Follow-up:
Previous treatment for warts (type, duration)
Response to treatment
Any new wart development
III. Past Medical History:
Underlying medical conditions (immunosuppression)
IV. Medications:
Current medications (including topical medications used for wart treatment)
V. Social History:
Recent contact with anyone with warts
VI. Physical Exam:
Vital signs (BP, HR, RR, Temp) – typically normal unless there are many warts
Skin exam:
Location, number, size, and appearance of warts (common, plantar, flat)
Assess for signs of inflammation or secondary infection
VII. Diagnostic Studies (usually not required):
In rare cases, a biopsy may be needed to differentiate a wart from another skin lesion.
VIII. Assessment:
Cutaneous warts based on clinical presentation (typical appearance and location).
Specific wart type (common, plantar, flat) based on location and appearance.
IX. Plan:
Treatment options depend on the type, severity, and location of the warts:
Topical keratolytics (salicylic acid, lactic acid): Over-the-counter option for common warts.
Cantharidin: Blistering agent applied by a healthcare professional for common and plantar warts.
Cryotherapy: Freezing with liquid nitrogen, effective for various wart types.
Immunomodulators (imiquimod): Topical cream to stimulate the immune response against warts.
Procedural treatments (laser therapy, surgical excision): May be considered for resistant warts or those in cosmetically sensitive areas.
Patient education on proper hygiene and avoiding self-manipulation to prevent spread.
X. Prognosis:
Warts can be successfully treated, but recurrence is possible.
Discuss the potential need for multiple treatment sessions and the importance of following treatment instructions.
XI. Notes:
Include any additional observations or concerns, such as patient’s understanding of the diagnosis and treatment plan, potential side effects of treatment, need for follow-up appointments, and potential referral to a dermatologist for more complex cases.
XII. Resources:
Consider providing patient education materials on cutaneous warts from reputable sources (e.g., American Academy of Dermatology, American Academy of Family Physicians).