Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Visit:
Suspected or confirmed CMV infection
Follow-up for CMV infection (immunocompromised patient)
Evaluation for CMV complications (e.g., pneumonitis, retinitis)
II. History of Present Illness:
Symptoms suggestive of CMV infection (may be absent, especially in immunocompromised patients):
Fever
Fatigue
Myalgias (muscle aches)
Mononucleosis-like syndrome (lymphadenopathy, sore throat)
Cough (if involving lungs)
Vision changes (if involving retinitis)
Underlying medical condition leading to immunosuppression (HIV/AIDS, transplant recipient, chemotherapy) – if applicable
Recent contact with individuals with CMV infection (especially relevant for newborns and pregnant women)
III. Past Medical History:
Underlying medical conditions (HIV/AIDS, organ transplantation)
Previous CMV infection (if known)
IV. Medications:
Current medications (including immunosuppressants, antiretrovirals for HIV)
V. Social History (consider as applicable):
Pregnancy status (important for potential fetal complications)
Recent travel (increased risk in CMV-naive individuals traveling to endemic areas)
Recent contact with young children (common carriers of CMV)
VI. Physical Exam:
Vital signs (BP, HR, RR, Temp) – may be elevated with active infection
General appearance (illness appearance)
Lymph node exam (lymphadenopathy may be present)
Fundoscopy (examination of the retina) – if CMV retinitis is suspected
VII. Laboratory Studies (consider as appropriate):
CMV serology (IgG and IgM antibodies):
IgG positive indicates past infection
IgM positive suggests recent infection or reactivation
CMV viral load (quantitative PCR):
Measures the amount of CMV virus present, helpful for diagnosis and monitoring treatment response
VIII. Imaging Studies (consider as appropriate):
Chest X-ray (if CMV pneumonitis is suspected)
Retinal exam by ophthalmology (if CMV retinitis is suspected)
IX. Assessment:
Suspected or confirmed CMV infection based on clinical presentation, laboratory tests (CMV serology and/or viral load).
Immunocompromised status (if applicable) and risk factors for CMV infection.
Severity of CMV infection (asymptomatic, symptomatic)
Potential CMV organ involvement (pneumonitis, retinitis) – if suspected based on symptoms or exam findings
X. Plan:
Treatment plan depends on the patient’s immune status, severity of illness, and presence of organ involvement:
Healthy individuals: CMV infection is often self-limited and may not require specific treatment. Supportive care (fluids, rest) may be sufficient.
Immunocompromised patients: Antiviral medications (e.g., ganciclovir, valganciclovir) may be used to treat or prevent CMV infection.
CMV organ involvement: Specific treatment based on the affected organ (e.g., corticosteroids for CMV retinitis) may be needed in addition to antiviral medications.
Pregnant women with confirmed CMV infection: Evaluation for fetal CMV infection and potential antiviral treatment may be considered by a high-risk pregnancy specialist.
Monitoring: Repeat CMV viral load testing to assess treatment response.
XI. Prognosis:
Discuss the prognosis based on the patient’s immune status, severity of CMV infection, and presence of complications.
For immunocompromised patients, emphasize the importance of ongoing monitoring and preventive measures to reduce the risk of CMV reactivation.
XII. 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 isolation precautions (to prevent transmission in some cases), and the importance of good hand hygiene to prevent CMV spread.
XIII. Resources:
Consider providing patient education materials on CMV infection from reputable sources (e.g., American Society for Transplantation and Cellular Therapy, Centers for Disease Control and Prevention (CDC)).