Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Reason for Visit:
Document the reason for this visit. Is this a patient with new-onset symptoms suggestive of encephalitis, or a follow-up visit after diagnosis?
History of Present Illness:
Onset and duration of symptoms:
Fever (may be high-grade)
Headache (may be severe)
Altered mental status (confusion, lethargy, delirium)
Seizures
Weakness
Speech difficulties
Coordination problems
Nausea and vomiting
Visual disturbances
Recent travel history (especially to areas with mosquito-borne encephalitis)
Insect bites (potential tick or mosquito exposure)
Recent illnesses (e.g., upper respiratory infection)
Immunosuppression (medications, underlying conditions)
Past Medical History:
Briefly document any relevant past medical conditions, surgeries, or allergies, especially those affecting the immune system.
Social History:
Inquire about tobacco use, alcohol consumption, and illicit drug use.
Medications:
List all current medications, including any over-the-counter medications and herbal supplements.
Allergies:
Document any known allergies, especially allergies to medications used in treatment.
Family History:
Inquire about a family history of encephalitis or autoimmune conditions.
Physical Exam:
Vital Signs: Include blood pressure, temperature, heart rate, respiratory rate.
Neurological Exam:
Assess mental status (alertness, orientation, memory)
Evaluate cranial nerve function
Assess motor function (strength, coordination)
Test reflexes
Assess for meningeal signs (stiff neck, Kernig’s sign, Brudzinski’s sign)
Laboratory:
Document any laboratory tests performed, such as:
Complete blood count (CBC): May show elevated white blood cell count if there is an infection.
Electrolytes: May show abnormalities due to dehydration and electrolyte imbalances.
Liver function tests (LFTs): May show elevations indicating inflammation.
Lumbar puncture: Cerebrospinal fluid (CSF) analysis is crucial for diagnosis. May show increased white blood cells, elevated protein, and presence of specific antibodies depending on the cause of encephalitis.
Viral PCR testing: Tests on blood or CSF to identify specific viruses (e.g., West Nile virus, herpes simplex virus).
Autoimmune encephalitis panel: May be considered if viral workup is negative.
Imaging:
Brain MRI: May be helpful to identify abnormalities in brain structure and rule out other causes of symptoms (e.g., brain tumors, abscesses).
Assessment:
Suspected encephalitis: Based on clinical presentation and ongoing evaluation.
If a specific cause is identified (e.g., viral, autoimmune), document the specific type of encephalitis.
Consider differential diagnoses depending on the presenting symptoms (e.g., meningitis, brain abscess, metabolic disorders).
Plan:
The goal of treatment is to address the underlying cause of encephalitis, manage symptoms, and prevent complications.
Treatment will depend on the identified cause:
Viral encephalitis: Antiviral medications (if specific virus is identified).
Bacterial encephalitis: Intravenous antibiotics.
Autoimmune encephalitis: Immunomodulatory therapy (e.g., steroids, intravenous immune globulin) to suppress the immune response.
Supportive Care:
Intravenous fluids for hydration and electrolyte replacement.
Antipyretics (fever reducers) and pain management medications.
Anticonvulsant medications (if seizures occur).
Respiratory support (if needed).
Follow-up:
Closely monitor vital signs, neurological status, and laboratory results.
Repeat CSF analysis as needed to monitor response to treatment.
Consider neurological rehabilitation to address any residual deficits.
Provide emotional support and patient education regarding the condition and potential long-term effects.
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant details regarding symptoms, risk factors, physical exam findings, laboratory and imaging results, and individualized treatment plan based on the underlying cause.