Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Subjective:
Describe the current symptoms related to lichen sclerosus, including:
Location of skin lesions (genital area most common, but can involve extragenital sites).
Appearance of lesions (thin, white, wrinkled skin, possible scarring).
Presence of itching, burning, or pain in the affected area.
Difficulty with urination, sexual intercourse, or hygiene due to lichen sclerosus.
Impact on quality of life and emotional well-being.
Objective:
Vital signs: Include temperature, pulse, respiratory rate, blood pressure.
Genital exam (if appropriate):
Describe the morphology and distribution of lichen sclerosus lesions (thin, white, wrinkled skin, possible scarring).
Assess for signs of inflammation (erythema, edema).
Note any vulvar narrowing or stenosis.
If male, examine the foreskin for involvement.
Extragenital exam (if applicable):
Describe any lesions on other body areas (e.g., breasts, axillae).
Imaging results (if applicable): Briefly describe relevant findings from recent imaging studies if performed (e.g., vulvar biopsy for diagnosis).
Assessment:
Diagnosis: Confirm the diagnosis of lichen sclerosus based on clinical presentation and potentially biopsy results.
Disease stage: Briefly describe the perceived stage based on the extent and severity of lesions (early vs. advanced with potential complications).
Complications: Mention any potential complications of lichen sclerosus, such as:
Vulvar stenosis (narrowing of the vaginal opening)
Increased risk of squamous cell carcinoma (discuss with patient but avoid causing undue anxiety)
Plan:
Treatment:
Outline the current treatment plan for lichen sclerosus, which may include:
Topical corticosteroids (first-line therapy) to reduce inflammation and itching.
Topical calcineurin inhibitors (alternative to steroids) for long-term management.
Estrogen therapy (for postmenopausal women) to improve skin health.
Recommend good hygiene practices and use of emollients to maintain healthy skin.
If complications are present (e.g., stenosis), discuss potential need for referral to a specialist (dermatologist or gynecologist) for further evaluation and treatment options.
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.