Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Genital ulcer(s) (inguinal, anorectal)
Pelvic pain
Inguinal lymphadenopathy (swollen lymph nodes in the groin)
History of Present Illness:
Onset, location, character, and duration of genital ulcers.
Associated symptoms (e.g., discharge, bleeding, pain with urination or defecation).
Recent sexual history (number of partners, condom use).
Travel history to areas with high LGV prevalence.
Past Medical History:
Sexually transmitted infections (STIs):
Previous diagnosis of LGV or other STIs (chlamydia, gonorrhea)
Underlying medical conditions (e.g., HIV infection can worsen LGV course).
Medications:
List all current medications, including antibiotics used for other conditions.
Allergies:
Mention any allergies to medications, particularly antibiotics.
Social History:
Sexual behavior (number of partners, condom use)
Substance use (can increase risk of risky sexual behavior)
Physical Exam:
Vital signs: Assess for fever (may be present in some cases).
Genital exam:
Inspect for genital ulcers (typically painless, with sharply defined borders).
Palpate for inguinal lymphadenopathy (unilateral or bilateral, often tender and matted).
Rectal exam (if indicated): Evaluate for rectal ulcers or proctitis (inflammation of the rectum).
Laboratory Tests:
Swab test from the ulcer: Test for presence of Chlamydia trachomatis (CT) and LGV using nucleic acid amplification tests (NAATs).
Serologic tests: These may not be diagnostic for LGV but can be used as supportive evidence. They are not routinely recommended due to limitations in sensitivity and specificity.
Complete blood count (CBC): May show elevated white blood cells if there is active infection.
Imaging Studies (not routinely used):
Ultrasound: May be used to assess for complications like abscess formation in the lymph nodes.
Assessment:
Diagnosis: State “suspected lymphogranuloma venereum” or “confirmed lymphogranuloma venereum” based on clinical presentation, testing results, and sexual history.
Severity of symptoms: Briefly describe the perceived severity of symptoms (pain, extent of ulceration, lymphadenopathy).
Plan:
Treatment:
Antibiotic therapy: A course of antibiotics (e.g., doxycycline, azithromycin) will be prescribed for a specific duration to eradicate the infection.
Pain management: Medications (e.g., analgesics) may be prescribed to manage discomfort associated with ulcers and lymphadenopathy.
Sitz baths: Warm sitz baths can provide pain relief and promote healing of anorectal complications.
Partner notification: It is crucial to advise the patient about the importance of partner notification to prevent further transmission.
Follow-up: Schedule follow-up visits to monitor treatment response, resolution of symptoms, and potential complications.
Education:
Educate the patient about LGV, transmission routes, symptoms, treatment options, and the importance of safe sexual practices (condom use, limiting sexual partners).
Discuss the importance of partner notification and encourage the patient to inform their sexual contacts to seek testing and treatment.
Follow-up:
Schedule follow-up visits within 1-2 weeks to monitor response to treatment and evaluate for complications (e.g., stricture formation).
Advise the patient to return sooner if they experience worsening symptoms or new concerning symptoms.
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. It is recommended to consult with relevant medical resources and LGV management guidelines for comprehensive care planning.