HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old man, originally from (XX), with a history of tuberculosis and lymphatic infection 11 years ago for which he completed treatment, who presents to the emergency department with 2-3 weeks of diffuse pruritic maculopapular rash.

Rash initially involved both hands, including palm area and neck, progressing to diffuse body rash, sparing facial area.  The patient reports no previous similar events.  He has been in contact with fiberglass particles at his construction work and used new cloth detergent approximately 2 weeks ago, which coincides with development of rash.

Denies fevers, chills, nausea, vomiting, diarrhea, dysuria, night sweats, loss of weight, decreased appetite, respiratory symptoms, sick contacts or travel.

He received prednisone 60 mg x1 and Benadryl 25 mg x1 in the emergency department with good symptomatic relief.

REVIEW OF SYSTEMS:  All other components of review of systems are negative or as described in history of present illness.

PAST MEDICAL HISTORY:  Mycobacterial infection treated 11 years ago, right foot surgery for removal of an accidentally included wood piece.

FAMILY HISTORY:  Father died of complications of asthma.

SOCIAL HISTORY:  Born in (XX), immigrated to the United States 7 years ago.  Lives in (XX).  Construction worker.  Denies drug, tobacco or alcohol use.  He is not sexually active.  Last sexual partner was approximately 2 years ago.  Reports consistent use of condoms.  No prior HIV test.  Vaccinations are up-to-date.

ALLERGIES:  No known drug or food allergies.

MEDICATIONS:  Prednisone 60 mg p.o. x1, Benadryl 25 mg p.o. x1.

PHYSICAL EXAMINATION:

GENERAL APPEARANCE:  Thin man, resting comfortably in bed, in no acute distress.

VITAL SIGNS:  Blood pressure 124/82, heart rate 60, respiratory rate 18, temperature 97.6 and pulse oximetry 100% on room air.

EYES:  No icterus.  Pink conjunctivae without petechia.

ENT:  Clear tympanic membranes and nasal turbinates and oropharynx.

NECK:  Bilateral neck fullness.  Supple.

LUNGS:  Clear to auscultation bilaterally.

HEART:  Regular rate and rhythm.  No murmurs, rubs or gallops.

ABDOMEN:  Nondistended, bowel sounds present, nontender and soft.  No organomegaly.

GENITOURINARY:  No open lesions.  Normal sized penis and testes.  No ureteral discharge.

LYMPH:  No neck, supraclavicular or axillary lymphadenopathy.

BACK:  No pain on palpation of vertebral processes or costovertebral angles.

MUSCULOSKELETAL:  No joint effusion, warmth.  Full range of motion throughout.

VASCULAR:  2+ throughout.

SKIN:  Dry skin with diffuse maculopapular rash and excoriation, sparing face.  No open lesions, ulcerations, scaling skin or discharge.

NEUROLOGICAL:  No gross neurological deficits.

PSYCHIATRIC:  Alert and active.  Appropriate.

LABORATORY DATA:  Sodium 131, potassium 3.8, chloride 102, CO2 31, anion gap 6, glucose 79, BUN 11, creatinine 0.89, calcium 9.0.  Total bilirubin is 0.5, AST 33, ALT 26, troponin 0.01, LDH 339, amylase 106.  WBC 3.1, hemoglobin 15.7, hematocrit 45.4, platelet 170,000, segmented cells 43, bands 2, lymphocytes 25, reactive lymphocytes 2 and eosinophils 17.

ASSESSMENT AND PLAN:  This is a (XX)-year-old gentleman with 2-3 weeks of diffuse erythematous maculopapular rash with facial sparing.  After carefully obtaining detailed history, he seems to have clear exposure to possible offending agents, including fiberglass, new detergent and possibly bed bugs.  Rash is consistent with an allergic dermatitis rather than an infectious process.  Although involvement of palms and soles can be seen in certain infectious process as syphilis and viral syndrome, we think history is more consistent with allergic reaction, which is supported by the presence of elevated eosinophils.  We think main therapy would consist of remove offending agents along with the application of topical steroid cream and antihistaminic therapy for symptomatic relief.  We agreed with RPR for evaluation of syphilis.

RECOMMENDATIONS:

1. Obtain RPR – syphilis IgE.
2. Remove offending agents.
3. Topical steroid cream and antihistaminic.
4. Follow up with primary care or Dermatology if no improvement in 1 week.

Thank you for this consultation.  Please contact infectious disease team if any questions or changes in the patient’s clinical status. Recommendations discussed with the emergency department team and handwritten note placed in the patient’s medical records.

PAST MEDICAL HISTORY: Negative for autoimmune disorders. She is otherwise healthy.

MEDICATIONS: None.

ALLERGIES: NONE.

FAMILY HISTORY: Father developed alopecia areata subsequent to daughter’s diagnosis.

SOCIAL HISTORY: The patient is a student and uses sunscreen prior to activities.

OBJECTIVE: Examination limited to the head and neck area shows, after removal of hair prosthesis, alopecia involving approximately 50-60% of her total scalp. There is complete hair loss with no evidence of scarring in the parietal and occipital area with a few white terminal hairs within these large patches of alopecia. There are normal appearing areas of hair around her frontal and scalp temples and patchy distribution on the vertex of the scalp. There is no loss of eyebrow or eyelashes area. The patient denies loss of any body hair.

ASSESSMENT: Alopecia areata in an ophiasis pattern.

PLAN: The patient was seen additionally by two other doctors who concurred with the diagnosis and treatment plan that was discussed with the patient and her mother. We discussed with the mother that sulfasalazine has been reported to be useful in alopecia areata based on one published study and report is that 23% of patients had regrowth with alopecia areata treated with sulfasalazine. We discussed with the patient and her mother that neither me nor the other doctors consulted has had any experience with the use of sulfasalazine in alopecia areata. Discussed with them that another alternative, that may be helpful, is topical anthralin treatment in combination with topical minoxidil. She has never had either of these medications in the interest of trying to avoid potential side effects. Certainly, the topical treatment has lots of potential side effects than sulfasalazine. Mother and the patient decided to go along with that treatment first. She is going to begin Drithocreme 1% starting at 10 minutes titrating up to 30 minutes over 3 weeks. The patient was cautioned about staining of clothing, bathroom fixtures, etc. from the medication and begin Rogaine 5% solution b.i.d., of which the patient was cautioned about potential for facial hair regrowth or change with the facial hair growth. Followup is scheduled in six weeks with the referring doctor.

CHIEF COMPLAINT: Followup skin check.

HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old Asian woman with significant past medical history of squamous cell carcinoma on the left infraorbital region, status post Mohs surgery. She also has a history of multiple basal cell carcinomas, previously treated at outside facilities, but does not remember exactly where they were or when they were treated. She also has a history of actinic keratoses, which has been treated in the past with cryotherapy as well as Efudex, and most recent Efudex treatment was in MM/DD/YYYY on the face and neck for persistent AKs. She also had a verruca treated in the past. She does note today one papule on her left plantar foot. She states that has been there for several months but does not give her symptoms.

PAST MEDICAL HISTORY: As per HPI as well as temporal arteritis.

MEDICATIONS: Updated and reviewed.

ALLERGIES: SULFA.

REVIEW OF SYSTEMS: The patient denies any fevers, chills, nausea, vomiting, weight changes or blurry vision.

PHYSICAL EXAMINATION:
GENERAL: The patient is alert and oriented x3 and has pleasant, appropriate affect and mood.
GENERAL APPEARANCE: The patient is a well-developed, well-nourished female in no acute distress, who appears stated age.
VITAL SIGNS: Pulse 66, respiratory rate 18, and blood pressure 134/72.
SKIN: A full skin examination was performed today, including the head, face, neck, chest, breast, back, axillae, abdomen, arms, hands, legs, feet, digits, nails, groin, and buttocks. Eyelids and conjunctivae were clear. Oral mucosa and lips showed no pigmented lesions. Scalp, trunk, extremities, and digits were palpated. No appreciated clubbing or cyanosis.

Of note, on examination, the patient has multiple skin-colored, stuck-on papules and plaques located on the scalp, face, trunk, as well as upper and lower extremities. She also has around fourteen 1 to 4 mm brown macules consistent with benign melanocytic nevi. No concerning features on dermoscopy. On the right clavicle area seen is a 4 mm erythematous papule with C-shaped telangiectasias on dermoscopy consistent with a dermal nevus. She has several others of these on her back.

On the left plantar foot, seen is a 4 mm verrucous papule consistent with a verruca. Palms and soles are otherwise clear. No appreciated lymphadenopathy in the cervical, supraclavicular lymph node groups. Left infraorbital region seen with well-healed scar from previous squamous cell carcinoma excision.

ASSESSMENT AND PLAN:
1. History of multiple nonmelanoma skin cancers, no evidence of recurrence.
2. History of actinic keratoses appreciated on exam today.
3. Multiple benign lesions, including seborrheic keratoses and verruca likely on the left plantar foot. One irritated seborrheic keratosis on the left neck was treated with cryotherapy x2 cycles. Blistering and wound care discussed with the patient.
4. We will have the patient return to clinic in six months or sooner with any new symptomatic or concerning skin lesions.

CHIEF COMPLAINT: Cracked feet.

HISTORY OF PRESENT ILLNESS: This patient was seen by Dr. John Doe for psoriasis in August of last year. She says that her psoriasis has been fairly well controlled with Dovonex and clobetasol topical medications. The patient complains of cracking and bleeding around her heels for the last couple of years. She says that it was never a problem when she was younger, and she has not been treating it with anything. She also complains of fungus in her toenails. She is very bothered by this, and she would like to discuss treatment options. She complains of a red spot on her right chin that has been present for one year. Initially, she thought it was a pimple, but since it has not gone away, she is concerned it could be skin cancer.

MEDICATIONS: Hydrochlorothiazide, fluoxetine, fish oil, Crestor, Centrum Silver, clonazepam, Prosed, and ibuprofen.

ALLERGIES: Penicillin.

PHYSICAL EXAMINATION: This is a pleasant (XX)-year-old Asian woman, who is awake, alert and oriented x3, in no acute distress with normal mood and affect. Skin examination included face, scalp, hair, neck, chest, abdomen, back, arms, legs, hands, and feet bilaterally and buttocks. On the right chin, there is a 3 mm pink, scaly plaque. On her toenails bilaterally, she has toenail polish, so it is difficult to assess whether there is nail discoloration. She does have some nail thickening and mild subungual debris. Around the heels of her feet bilaterally, she has healing fissures. She does have hyperkeratosis and dry skin.

IMPRESSION AND PLAN:
1.  Actinic keratosis x1 on the right chin. After verbal consent was obtained, this was treated with cryotherapy. Wound care was discussed.
2.  Onychomycosis. Fungal nail culture was sent. We will call her with the results.
3.  Xerosis. We prescribed 50% urea cream b.i.d. The patient was reassured.

FOLLOWUP:  In six months to reassess the onychomycosis and further discuss treatment options, sooner p.r.n.

OBJECTIVE:  The patient is alert and oriented x3. There are erythematous crusted, slightly weepy plaques on the right fourth finger and right first finger and dorsal surface of the hand with less involvement on the palms. There are hypopigmented, slightly dry, scaly patches on the proximal arms and upper chest area, scattered eczematous 3 cm patches on the right cheek and lateral neck. The rest of complete skin examination is unremarkable.

ASSESSMENT:  Atopic eczema.

PLAN:
1.  We advised discontinuing the Caladryl and Neosporin to the hands. We think she has developed contact dermatitis. Discussed with her protecting her hands from repeated exposure to water with wearing gloves.
2.  Clobetasol ointment to the hands b.i.d. for two weeks, then triamcinolone acetonide 0.1% ointment b.i.d. for two weeks.
3.  She can continue with the Elidel 1% cream b.i.d. p.r.n. facial eczema.
4.  We advised she discontinue tanning as we think it is worsening the dyschromia. She does have postinflammatory hypopigmentation from the eczema. She questions if Tri-Luma cream would be helpful with fading that is on her arms and legs. We told her it is highly unlikely it is going to have much of an impact, and we advised her regarding the cost of the medication, which will not be covered with insurance. The patient did not wish to pursue that. Further followup for the eczema scheduled for one month.

Sample #2

SUBJECTIVE:  The patient is a (XX)-year-old gentleman who comes in today for a skin check. He has had two melanomas in the past; one was a Clark level IV 4.8 mm melanoma on his left arm. There were five mitoses per square millimeter with no ulceration. This was excised 1-1/2 years ago with a negative sentinel lymph node biopsy. Six months ago, he had another lesion distal to this, on his left wrist, that was removed and was shown to be a 1.4 mm thick melanoma level IV, less than one mitosis per square millimeter with ulceration absent. Of note, for the second melanoma, there was a question of epidermotropic metastasis; however, there was an in situ component to this suggesting a primary lesion but could not completely rule out epidermotropic metastasis on the pathology report. This was re-excised with a negative sentinel lymph node biopsy. The patient currently notes that he is doing well with no new or changing moles. He does point to a wart on his third finger of his left hand that he has had for quite some time. He also has one on the right finger web between the first and second digit as well.

OBJECTIVE:  The patient is well appearing with normal respiratory effort. He is oriented with normal affect and mood.

ASSESSMENT AND PLAN:
1.  Wart: On his third finger, on his left hand, he had a 3-4 mm hyperkeratotic papule, and this was frozen with liquid nitrogen with three brief freeze-thaw cycles. On the next visit, we will freeze it a bit harder if it appears to persist, and he did not get too much of an inflammatory response. Also, on his right finger web, he had a 3 mm papule that was frozen with liquid nitrogen as well.
2.  History of melanoma x2: He had on his left forearm and left wrist two well-healed scar sites with no evidence of pigmentation or nodularity in or around the scar sites, as usual amelanotic. He will watch for pink lesions that are persistent, and he will continue self-skin checks.
3.  Nevi: The patient had relatively few brown macules and papules scattered on torso and extremities but nothing concerning for malignancy.

We will see him back in Dermatology in one month to treat his warts, if it is still present, and in three months for his next skin check.

OBJECTIVE:  The patient is alert and oriented x3 with normal mood and normal body habitus. The patient’s frontal scalp, face, neck, chest, abdomen, back, upper and lower extremities, hands, feet bilaterally were examined, and there were 2-4 mm pink, rough, keratotic macules on the frontal scalp, on the right and left upper malar area, and on the right distal dorsal arm. The rash was localized to the shoulders, upper back, and proximal legs. They were 1 to 2.5 cm, pink, very slightly scaly plaques. There was mild erythema with slight scale on the palmar surface of both hands and the fingertips show mild fissuring.

ASSESSMENT:
1.  Chronic hand eczema.
2.  Nummular eczema on the shoulders and legs.
3.  Actinic keratoses on the scalp, cheeks, and arms.

PLAN:
1.  Liquid nitrogen 10-second freeze for destruction of nine actinic keratoses.
2.  Elocon ointment b.i.d. to the nummular eczema. Discussed beginning regular use of moisturizer to all of his skin. If the rash does not respond in the next 2 to 3 weeks, we asked him to call back.
3.  The patient will continue with the triamcinolone acetonide 0.1% ointment b.i.d. for the hand eczema, which he has found helpful.
4.  Follow up again in one year.

OBJECTIVE:  Alert and oriented x3. On examination of her face, neck, chest, breasts, abdomen, back, upper and lower extremities, hands and feet bilaterally, there are numerous erythematous, slightly keratotic, 2-10 mm in diameter macules on the dorsal surface of the proximal and to a great extent distal arms, and on her proximal and distal anterior legs. Posterior legs show very few lesions. No lesions on the proximal posterior legs. No lesions on the trunk. No lesions on the face. There is mild erythema on her upper chest and upper back corresponding to recent radiation therapy.

ASSESSMENT:  She has numerous actinic keratoses on the sun exposed areas of the arms and legs that are becoming markedly inflamed with chemotherapy. This is most likely reaction to the carboplatin.

PLAN:  The patient was reassured with explanation of the eruption. We discussed with her that there is no reason to discontinue the chemotherapy and that actually this will be quite beneficial to the numerous precancerous lesions on her skin; that with continued chemotherapy, these are likely to eventually resolve. We discussed with her that her skin is more photosensitive, and she should be trying to protect her skin with clothing for any outdoor activities. She states she has been avoiding outdoor activities largely. We advised Aquaphor healing ointment to the upper and lower extremities several times a day for symptomatic relief, and she can certainly apply this prior to chemotherapy. Followup, because of history of SCC, scheduled for six months.

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SUBJECTIVE:  The patient is a (XX)-year-old female here for her six-month history of tender nodules of her legs of unclear etiology. The patient is currently using Unna boots weekly and reports her nodules are significantly improved. She feels overall she is doing well. She developed nodules on the lower extremities. She noticed small tender nodules on her right calf. Then, over the course of the following three months, she developed further lesions on the left ankle and the left pretibial area. Her dermatologist initially suspected panniculitis versus erythema nodosum, and she was treated with Augmentin and prednisone with no improvement. She had an excisional biopsy performed, which showed an acute abscess with superficial ulceration, abundant gram positive cocci. Features favored infectious process, component of stasis dermatitis was possible. There was no evidence of any underlying primary vasculopathy or typical features recognizable from a primary folliculitis. Her tissue cultures at that time revealed MSSA and Pseudomonas; however, this was taken from the out base of the ulcer. Fungal culture, bacterial culture, and AFB cultures were all negative. In addition to her above treatment, she has had PPD that was negative. She was treated with topical steroids, NSAIDs including diclofenac and meloxicam, without improvement. She also was tried with minocycline 100 mg b.i.d. for two weeks and also Bactrim. She started with her application of Unna boots and also 50 mg of dapsone daily. She has completed five weeks of Unna boot treatment and had significant improvement over the past several weeks. She denies any new lesions. She has not had any drainage. No fever or chills. No neuropathy symptoms, weakness, or fatigue.

OBJECTIVE:  Today, she is alert and oriented, in no acute distress, nontoxic. Focused cutaneous exam of the bilateral lower extremities was noted to have along the right posterior calf approximately 3 x 2 mildly tender hyperpigmented violaceous plaques that appear more atrophied today. She has one pinpoint ulcer noted along the left calf, left malleolus. There are several small scattered erythematous hyperpigmented nodules resolving. Her pulses are intact. There is no edema noted.

ASSESSMENT AND PLAN:  Six-month history of tender nodules of unclear etiology, thought to be a possible reactive panniculitis from previous bacterial infection or nonspecific panniculitis, most probably related to her varicose veins. To date, her cultures have been negative. She continues to improve using dapsone 50 mg daily. She did a CBC, pending. She is starting to improve with Unna boot therapy. She will continue Unna boots and will follow up in clinic in one week or sooner if there is any new problem.

More Derm SOAP Note Samples

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SUBJECTIVE:  The patient is a (XX)-year-old woman who comes in today for psoriasis. She notes that the psoriasis is actually getting a bit worse on her forearms. She only has it there. She also had some erythema on her nasal columnar that we had frozen with liquid nitrogen for the chance that it could be an actinic keratosis. She also has some brown discoloration in the right nasal ala that we were watching and did look relatively benign and she notes it has not changed. She notes she does not really go out much. She is using DesOwen lotion twice a day to the elbows as well as desonide twice a day.

OBJECTIVE:  Well-appearing female, normal respiratory effort, oriented, normal affect and mood. Exam included the forearms and the nose.

ASSESSMENT AND PLAN:  Psoriasis: The patient had several very thin pink plaques on her forearms, and it does look like she has new patches of psoriasis. We discussed that since she does not get really any sunlight, to give herself 15 minutes every day and that itself can help clear psoriasis. She can continue on with the desonide twice a day and the Dovonex twice a day as the lesions do look relatively thin and minimal. She had a little bit of macular erythema on the nasal columnar but no evidence of any scaling, and we discussed with her she can just simply watch this. She also had the brown discoloration on the right nasal ala that looks actually improved from last time and not concerning, and we will continue to watch this. It could be a small patch of postinflammatory hyperpigmentation. We will see her back in six months.