appear)
Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Painful blisters or sores around the mouth or lips (may be present or
described as a prodrome – tingling or burning sensation before sores
appear).
Burning, itching, or tingling sensation in the affected area (often
precedes the appearance of sores).
History of Present Illness:
Onset, duration, and frequency of outbreaks.
Triggering factors (e.g., stress, sun exposure, illness).
Location, number, and size of sores.
Burning or stinging sensation associated with the sores.
Stage of the outbreak (prodrome, blister formation, crusting, healing).
Past Medical History:
Underlying medical conditions that may affect immune function
(e.g., HIV/AIDS, immunosuppressive medications).
History of previous orolabial herpes outbreaks.
Social History:
Recent close contact with someone with a known herpes infection
(cold sore or genital herpes).
Family History:
Family history of herpes simplex virus (HSV) infection.
Physical Examination:
Perioral examination: Inspect the lips and surrounding skin for
presence, location, and number of lesions. Note the stage of the lesions
(vesicles, pustules, ulcers, or crusting).
Palpate for lymphadenopathy (swollen lymph nodes) in the submandibular
region.
Diagnostic Tests:
(Not routinely necessary for typical orolabial herpes)
Viral culture: A scraping from a lesion can be cultured to confirm
HSV infection. Results may take several days.
Tzanck smear: Rapid test with microscopic examination of a smear from
a lesion to detect multinucleated giant cells suggestive of herpesvirus
infection. Less specific than viral culture.
Assessment:
Orolabial herpes: Based on characteristic clinical features
(painful blistering lesions around the mouth or lips) and consistent history
of outbreaks.
Stage of the outbreak: Identify the current stage (prodrome,
blister formation, crusting, healing) to guide treatment decisions.
Frequency of outbreaks: Consider the frequency of outbreaks
(episodic or very frequent) to determine if antiviral prophylaxis may be
beneficial.
Differential Diagnoses:
Consider other conditions that may mimic orolabial herpes:
Angular cheilitis (inflammation at the corners of the mouth)
Bacterial impetigo (superficial skin infection)
Allergic contact dermatitis
Plan:
Treatment: Options include:
Topical antiviral medications (e.g., acyclovir, penciclovir) applied
directly to the lesions may shorten the duration of the outbreak
and reduce symptoms. Early initiation (during prodrome) is most
effective.
Over-the-counter pain relievers (e.g., acetaminophen, ibuprofen)
can help manage pain and discomfort.
Supportive care: Recommend cool compresses to reduce inflammation
and promote healing. Encourage adequate hydration to prevent drying
of the lesions.
Prevention: Discuss strategies to reduce the frequency and severity of
outbreaks, such as avoiding triggers, sun protection, and good hand hygiene
to prevent autoinoculation (spreading the virus to other areas of the body).
Follow-up: Schedule a follow-up appointment if symptoms worsen or
do not improve within a week, or if there are concerns about complications
(e.g., eye involvement).
Prognosis:
Orolabial herpes is a chronic viral infection with recurrent outbreaks.
Treatment can help manage symptoms and reduce the duration of outbreaks.
Patient Education:
Educate the patient about orolabial herpes, the cause (herpes simplex
virus), transmission, and treatment options.
Discuss the importance of avoiding spreading the virus to others
(especially those with weakened immune systems or newborns).