Date:
Patient:
MRN:
Clincian: (Primary Care Physician, Urologist, Gynecologist, Infectious Disease Specialist)
Reason for Visit:
New diagnosis of genital herpes
Follow-up for established genital herpes
Evaluation of symptoms (outbreak or suspected exposure)
Discussion of treatment options and prevention strategies
History of Present Illness:
New Diagnosis:
Date of suspected exposure (if known)
Onset, duration, and severity of symptoms (genital ulcers, pain, burning, itching)
Presence of any associated systemic symptoms (fever, malaise, lymphadenopathy)
Established Diagnosis:
Frequency and severity of outbreaks
Triggers for outbreaks (stress, menstruation)
Response to previous treatment approaches (antiviral medication)
Sexual history (number of partners, condom use)
Past Medical History:
Underlying medical conditions (HIV infection can worsen herpes outbreaks)
Immunosuppressive medications (can increase risk of severe outbreaks)
Social History:
Sexual activity level
Relationship status
Physical Exam:
Genital exam (if appropriate):
Presence, location, and characteristics of genital ulcers (vesicles, pustules, scabs)
Tenderness in inguinal lymph nodes
May be normal if no outbreak is present.
Labs:
Viral swab or PCR test: Considered for new or atypical presentations, or if confirmation is needed.
Blood tests for HIV or other sexually transmitted infections (STIs) may be considered based on risk factors.
Assessment:
Summarize the diagnosis:
Confirmation of new or established genital herpes diagnosis based on clinical presentation, testing (if performed), and patient history.
Stage of infection (primary or recurrent outbreak) if applicable.
Plan:
Outline the treatment plan based on the assessment:
New Diagnosis:
Antiviral medication (acyclovir, valacyclovir, famciclovir) to shorten the duration and severity of the first outbreak.
Education on safe sex practices and herpes transmission.
Established Diagnosis:
Discuss suppressive therapy with daily antiviral medication (may be considered to reduce frequency and severity of outbreaks, especially for patients with frequent recurrences).
Discuss episodic therapy with antiviral medication (initiated at the first signs of an outbreak to shorten its duration).
Partner notification and counseling is recommended.
Prognosis:
Briefly discuss the prognosis. Genital herpes is a lifelong infection, but outbreaks can be managed with medication.
Emphasize the importance of safe sex practices to prevent transmission.
Education:
Document any education provided to the patient regarding:
The nature of genital herpes, its symptoms, and transmission routes
The benefits and potential side effects of antiviral medications
Strategies for reducing the risk of outbreaks (stress management, healthy lifestyle)
The importance of safe sex practices and partner communication
Resources for support and information about herpes
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about outbreaks, transmission, or emotional impact.
Consider the patient’s emotional well-being and offer support or referral for mental health services if needed.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a healthcare professional for diagnosis, treatment recommendations, and prognosis.