Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Subjective:
Describe the current symptoms related to lichen planus, including:
Location and distribution of itchy skin lesions (violaceous, papules, Wickham’s striae).
Severity and character of itch (burning, stinging).
Any change in the extent or intensity of symptoms since the last visit.
Impact of lichen planus on sleep, daily activities, and quality of life.
If oral lichen planus is present, inquire about:
Oral pain or burning sensation.
Difficulty eating or speaking.
Taste alterations.
Objective:
Vital signs: Include temperature, pulse, respiratory rate, blood pressure.
Skin exam:
Describe the morphology, location, and distribution of lichen planus lesions (e.g., violaceous, papules, Wickham’s striae).
Note the presence of koebnerization (development of lesions at sites of trauma).
Examine for mucosal involvement (e.g., oral lichen planus with white plaques, erosions).
Assess for nail involvement (e.g., pitting, pterygium).
Imaging results (if applicable): Briefly describe relevant findings from recent imaging studies if performed (e.g., biopsy for diagnosis).
Assessment:
Diagnosis: Confirm the diagnosis of lichen planus based on clinical presentation and potentially biopsy results.
Disease subtype: If applicable, specify the subtype of lichen planus (e.g., oral lichen planus, erosive lichen planus).
Severity: Briefly describe the perceived severity based on the extent of lesions, symptom intensity, and impact on daily life.
Plan:
Treatment:
Outline the current treatment plan for lichen planus, which may include:
Topical corticosteroids (first-line therapy) to reduce inflammation and itching.
Topical calcineurin inhibitors (alternative to steroids) for long-term management.
Oral medications (corticosteroids, immunosuppressants) for severe or widespread disease (consult specialist if needed).
Antifungal medications if suspected candidiasis is present in the oral cavity.
Recommend lifestyle modifications to manage itch (e.g., cool compresses, loose clothing, stress management).
Follow-up:
Schedule the next clinic visit for follow-up based on the severity and response to treatment.
Instruct the patient to return sooner if symptoms worsen or they experience new concerns.