Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
White patches or plaques on the tongue or inner cheeks (oral thrush)
Soreness or burning sensation in the mouth
Difficulty swallowing (rare)
Loss of taste (uncommon)
History of Present Illness:
Onset, duration, and severity of symptoms.
Appearance, location, and ease of removal of oral patches.
Presence of pain or discomfort.
Any recent changes in taste or swallowing.
Past Medical History:
Underlying medical conditions that may increase risk of oral candidiasis
(e.g., diabetes, HIV/AIDS, immunosuppression).
Recent use of antibiotics, corticosteroids, or inhalers (can disrupt
oral microbiome).
History of previous episodes of oral candidiasis.
Medications:
List of current medications (including inhalers) to identify
potential contributing factors.
Social History:
Use of tobacco products (smoking or smokeless tobacco can irritate
the mouth and increase susceptibility to fungal infections).
Use of dentures (poorly fitting dentures can trap moisture and contribute
to fungal growth).
Dental History:
Recent dental procedures or presence of ill-fitting dentures.
Oral Examination:
Inspect the tongue, inner cheeks, palate, and throat for presence, location,
color, and adherence of oral patches.
Assess for signs of inflammation, redness, or sores.
Diagnostic Tests:
(Not routinely necessary for typical oral candidiasis)
KOH smear: A scraping from the oral lesions can be microscopically
examined for fungal elements (yeast cells and hyphae).
Fungal culture: May be considered in severe or recurrent cases to
identify the specific fungal species.
Assessment:
Oral candidiasis: Based on characteristic clinical features
(white patches or plaques in the mouth) and consistent history.
Severity of infection: Consider the extent and location of oral patches and the degree of discomfort experienced by the patient.
Predisposing factors: Identify any underlying medical conditions
or medications that may have contributed to the development of oral candidiasis.
Differential Diagnoses:
Consider other conditions that may mimic oral candidiasis:
Lichen planus (inflammatory skin condition affecting the mouth)
Leukoplakia (white patches due to abnormal cell growth in the mouth)
Plan:
Treatment: Choice of treatment depends on the severity of infection
and the patient’s overall health. Options include:
Topical antifungal medications (e.g., clotrimazole, nystatin,
miconazole) in the form of lozenges, troches, or gels applied directly to the
lesions.
Swish and swallow antifungal medications (for more severe cases).
Addressing underlying medical conditions that may be contributing
to oral candidiasis.
Dietary modifications: Recommend a bland diet and avoid irritating
substances (e.g., spicy foods, alcohol) that may worsen discomfort.
Oral hygiene: Encourage good oral hygiene practices (brushing twice
daily and flossing) to remove fungal spores and debris.
Denture care: If dentures are present, instruct on proper cleaning
and disinfection to prevent fungal growth.
Follow-up: Schedule a follow-up appointment to monitor treatment
response and ensure resolution of symptoms.
Prognosis:
Oral candidiasis is usually a treatable condition. Early diagnosis
and treatment generally lead to a good prognosis. However, recurrences
can occur in patients with predisposing factors.
Patient Education:
Educate the patient about oral candidiasis, contributing factors,
treatment options, and preventive measures (e.g., maintaining good oral
hygiene).
Advise the patient to contact their healthcare provider if symptoms
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worsen or do not improve with treatment.