How do you document findings of oral thrush?

Documentation of Oral Thrush Findings

When documenting oral thrush, clinicians should record the presence of characteristic whitish, creamy plaques on the oral mucosa that can be scraped off, along with any associated symptoms such as burning sensation or pain.

Clinical Examination and Documentation

Visual Examination

• Document the specific location of lesions:
  • Buccal mucosa
  • Tongue surface
  • Palate
  • Lips
  • Other areas of oral cavity 1

Characteristic Findings to Document

• Appearance of lesions:
  • Creamy white, plaque-like lesions 1
  • Whether lesions can be easily scraped off (distinguishing feature from other white lesions) 1
  • Presence of erythematous patches without white plaques (less common presentation) 1
  • Angular cheilitis, if present 1, 2

Associated Symptoms

• Document any reported symptoms:
  • Burning sensation 3
  • Pain or discomfort
  • Taste alterations
  • Difficulty eating or swallowing

Diagnostic Confirmation

Microscopic Examination

• Document results of microscopic examination:
  • Potassium hydroxide (KOH) preparation showing characteristic pseudohyphal yeast forms 1
  • Note: This is the standard laboratory confirmation method for oral thrush

Culture Results

• If culture was performed:
  • Document the Candida species identified (most commonly C. albicans) 4, 3
  • Note any antifungal susceptibility testing results, especially if treatment failure is a concern 5

Risk Factors and Associated Conditions

Document relevant risk factors:

• Immunosuppression status 1, 3
• HIV/AIDS status 1, 5
• Recent antibiotic use
• Corticosteroid use (inhaled or systemic)
• Denture use and fit 3
• Oral hygiene status 3
• Diabetes status
• Other medications that may predispose to candidiasis

Treatment Plan

Document the prescribed treatment:

• Medication name, dosage, frequency, and duration
• For example: "Fluconazole 150mg single dose" 6 or "Topical antifungal preparation"
• Patient instructions for medication use
• Follow-up recommendations

Differential Diagnosis Considerations

If the diagnosis was uncertain, document other conditions considered:

• Leukoplakia
• Lichen planus 2
• Erythema migrans 2
• Pemphigus vulgaris 1
• Other white lesions of the oral cavity

Follow-up Documentation

For subsequent visits, document:

• Response to treatment
• Persistence or resolution of lesions
• Need for additional treatment
• Any complications

Common Pitfalls to Avoid

• Failing to distinguish oral thrush from other white lesions that cannot be scraped off
• Not documenting the extent and severity of the infection
• Overlooking potential underlying systemic conditions
• Missing documentation of risk factors that need to be addressed
• Failing to document treatment response at follow-up visits

Proper documentation of oral thrush is essential for appropriate treatment, monitoring of response, and identification of potential underlying conditions that may require further evaluation.