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Dermatology . . . Page 2


 

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Edited Sample Report

Thank you for asking me to see this **patient. She gives a history of a lesion developing on the left lower eyelid. This has been asymptomatic. There is also a long-standing history of dermatitis symptoms involving the face, neck, and upper trunk. She does not recall any specific childhood atopy.

Exam: Revealed a small seborrheic keratosis of the left lower eyelid margin. There was also evidence of subacute dermatitis with erythema and scaling present on the face, neck, and left shoulder region.

No treatment was necessary for the small keratosis at present. I feel she most likely has adult atopic and irritant dermatitis but allergic contact dermatitis is also in the differential diagnosis. She will start on the above treatment measures with further review in one month.

Diagnoses: 1. Seborrheic keratosis of left lower eyelid.
                      2. Dermatitis of face and upper trunk -- differential diagnosis to include atopic and irritant dermatitis versus allergic contact dermatitis.

Plan: 1. No treatment necessary for seborrheic keratosis.
         2. Westcort 0.2% cream applied b.i.d.
         3. Regular use of emolients.
         4. Patch testing in reserve.

Edited Sample Report

Thank you for asking me to see this pleasant patient in re-referral. He was last assessed in December *****, in the interim training for *****, and is not involved in any other ****** activities at work.I previously performed patch tests and this was negative to baking set antigens, although he showed a mild reaction to mercapto mix which is an allergen found in rubber products. The patient states he does not wear latex or rubber gloves on a regular basis at present. He finds that he will develop persistent symptoms involving both the hands and feet with pruritic vesicles and subsequent scaling. He has also had some involvement of the wrists, and antecubital and popliteal fossae regions. He is not on any current treatment measures.

Exam: Revealed vesicles and erythema affecting the lateral aspects of the right third, fourth, and fifth fingers as well as the dorsal aspect of the right first toe. Subacute dermatitis with erythematous papules and scaling was seen on the volar right wrist as well as antecubital and popliteal fossae regions.

I believe this is an ongoing process of dyshidrotic and nummular dermatitis. He most likely has underlying atopic tendencies. I feel that irritant factors at work such as frequent hand-washing may exacerbate his symptoms but it does not appear that he has a specific contact allergy reaction. He was started on the above topical therapy and I have also suggested ongoing protectant measures with use of Prevex cream. He did not appear to require any absence from employment duties at present. He will return for further review in three weeks.

Diagnosis: Dyshidrotic and nummular eczema.

Plan: Ultravate cream applied b.i.d. to involved areas of hands and feet.


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