Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
New or follow-up for molluscum contagiosum (MC)
(Specify) Asymptomatic flesh-colored, dome-shaped papules with a central umbilication (navel-like depression) typically on the face, trunk, or extremities.
History of Present Illness:
Onset, duration, and number of lesions.
Location(s) of lesions (face, trunk, extremities, genitals).
Any itching or discomfort associated with the lesions.
Recent contact with someone with MC.
Past Medical History:
Underlying medical conditions (immunodeficiency can worsen MC).
History of atopic dermatitis (eczema) (may be associated with MC).
Medications:
List all current medications.
Social History:
Recent close contact with children (most common transmission route).
Family History:
Family history of MC (uncommon).
Physical Exam:
Skin examination:
Identify typical flesh-colored, dome-shaped papules with a central umbilication.
Note the location and number of lesions.
Assess for any signs of secondary bacterial infection (redness, pus).
Laboratory Tests:
Not typically needed for diagnosis.
Skin biopsy (may be considered in atypical cases).
Assessment:
Molluscum contagiosum: Based on the characteristic clinical presentation (papules with central umbilication) and possibly a history of contact with someone with MC.
Differential Diagnoses:
Consider other skin conditions with similar appearance, such as:
Acne vulgaris
Warts
Folliculitis
Plan:
Treatment (may not be necessary if lesions are asymptomatic):
Observation: MC often resolves spontaneously within 1-2 years.
Cryotherapy: Freezing the lesions with liquid nitrogen.
Topical medications: Cantharidin or salicylic acid applied directly to the lesions.
Extraction: Removal of the lesions with sterile instruments (performed by a healthcare professional).
Patient education:
Reassurance that MC is a benign, self-limited viral infection.
Advise against scratching or picking at the lesions to prevent spread.
Discuss the contagious nature of MC and avoiding close contact until lesions resolve.
Follow-up: Schedule follow-up visits to monitor response to treatment and assess for resolution of lesions.
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. Molluscum contagiosum is a self-limited viral infection but can be bothersome. Treatment options are available to address symptomatic lesions or expedite resolution.