Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Encounter]
Subjective:
History of present illness:
Onset and duration of symptoms (fever, chills, rigors, new or worsening respiratory symptoms, abdominal pain, diarrhea, altered mental status).
Recent hospitalizations, surgeries, or use of central lines/catheters.
Underlying medical conditions (immunosuppression, malignancies, recent antibiotic use).
Allergies: Medications (antifungal agents)
Objective:
Vital Signs: (BP, HR, RR, Temp)
Physical Exam:
General: Appearance of illness (tachypnea, hypotension)
Skin: Rash (petechiae, macules)
Cardiovascular: Signs of shock (tachycardia, hypotension)
Respiratory (if pulmonary involvement suspected)
Abdomen (if abdominal involvement suspected)
Neurologic (if CNS involvement suspected)
Laboratory:
Complete blood count (CBC) with differential (looking for leukopenia or neutropenia)
Blood cultures (results and organism identification if available)
Serum electrolytes, creatinine, liver function tests
Beta-d-glucan test (if available) – a non-specific marker for fungal infection
Antifungal susceptibility testing (if blood culture positive for Candida)
Imaging:
Chest X-ray or CT scan (if pulmonary involvement suspected)
Abdominal imaging (if abdominal involvement suspected)
Brain imaging (if CNS involvement suspected)
Assessment:
Invasive candidiasis (suspected or confirmed)
Site of involvement (bloodstream, pulmonary, disseminated, CNS)
Underlying risk factors for invasive candidiasis
Plan:
Diagnostic workup (if not yet confirmed):
Consider further source control procedures (e.g., removal of catheters) based on suspected site of infection.
Consider additional testing as needed (e.g., BAL for suspected pulmonary involvement).
Antifungal therapy:
Initiate or adjust antifungal therapy based on suspected/confirmed diagnosis and antifungal susceptibility testing. Common antifungal medications for invasive candidiasis include fluconazole, caspofungin, micafungin, and anidulafungin.
Source control:
Remove or replace any central lines or catheters suspected to be the source of infection.
Supportive care:
Management of hemodynamic instability (fluids, vasopressors if needed).
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.
Repeat blood cultures:
Repeat blood cultures to monitor response to treatment.
Imaging follow-up:
Schedule follow-up imaging (chest X-ray, CT scan) as needed to monitor response to treatment.
Follow-up:
Schedule next appointment in [interval] based on clinical response.