Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Encounter]
Subjective:
History of present illness:
Onset and duration of symptoms (fever, cough, chest pain, shortness of breath, hemoptysis (coughing up blood), new or worsening neurological symptoms).
Recent hospitalizations, surgeries, or immunosuppressive therapy.
Underlying medical conditions (chronic obstructive pulmonary disease (COPD), cystic fibrosis, neutropenia).
Allergies: Medications (mold-active antifungal agents)
Objective:
Vital Signs: (BP, HR, RR, Temp)
Physical Exam:
General: Appearance of illness, respiratory distress
Chest: Auscultation for abnormal breath sounds (rales, wheezing)
Neurologic (if CNS involvement suspected)
Imaging:
Chest X-ray or CT scan findings suggestive of invasive aspergillosis (infiltrates, nodules, cavities).
Brain imaging (if CNS involvement suspected)
Laboratory:
Serum galactomannan (if available) and Aspergillus PCR (polymerase chain reaction) testing results.
Complete blood count (CBC) with differential (looking for neutropenia)
Bronchoalveolar lavage (BAL) culture results (if performed)
Assessment:
Invasive aspergillosis (suspected or confirmed)
Site of involvement (pulmonary, disseminated, CNS)
Underlying risk factors for aspergillosis
Plan:
Diagnostic workup (if not yet confirmed):
Consider bronchoscopy with BAL and fungal cultures/pathology.
Repeat or consider additional Aspergillus-specific testing (galactomannan, PCR) based on clinical suspicion.
Antifungal therapy:
Initiate or adjust antifungal therapy based on suspected/confirmed diagnosis and antifungal susceptibility testing (if available). Common antifungal medications for invasive aspergillosis include voriconazole, isavuconazole, and liposomal amphotericin B.
Immunosuppressive therapy:
Review and potentially adjust immunosuppressive medications if feasible.
Supportive care:
Management of respiratory failure (oxygen therapy, mechanical ventilation if needed).
Management of other supportive needs based on patient’s condition.
Infectious disease consultation: Consider consulting with an infectious disease specialist for guidance on management.
Imaging follow-up:
Schedule follow-up chest X-ray or CT scan to monitor response to treatment.
Repeat Aspergillus-specific testing:
Repeat galactomannan or PCR testing periodically to monitor response to therapy.
Follow-up:
Schedule next appointment in [interval] based on clinical response.