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Dermatology . . . Page 4


 

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Edited Sample Report

Thank you for sending along this pleasant patient for my assessment. She presents for assessment of multiple lesions developing on the forearms and dorsal hands. These have not been previously treated. She has Type III pigmentation of the skin and has had significant sun exposure in the past. There is no past history of cutaneous carcinoma.She will also develop erythema and pustules affecting the nose.

Exam: Revealed well-defined "stuck-on" keratoses of the dorsal hands and forearms. Erythema with pustules and mild edema of the nose was also present.

She was given treatment with cryotherapy to symptomatic keratoses on the dorsal right hand and forearm region.She will start on topical therapy for rosacea and was also given advice as to regular sun protection measures.

Diagnoses: 1. Stucco keratoses of arms and legs.
                      2. Rosacea of nose.

Plan: 1. Symptomatic keratoses treated with liquid nitrogen cryotherapy.
          2. 1MetroGel applied b.i.d. for treatment of rosacea.

Edited Sample Report

Thank you for sending along this pleasant patient for my assessment. She presents for assessment of lesion developing on the left angle of the jaw for the past 3-4 years. This apparently has been treated on several occasions with cryotherapy without significant response. She has had a past history of actinic damage and has possibly had cutaneous carcinoma of the right lower eyelid region previously surgery excised. She has Type II pigmentation of the skin and had frequent sunburns in the past. Her health is stable, although she has a history of cardiomyopathy and is on numerous medications, including digoxin, Coumadin, a diuretic, and anti-hypertensive.

Exam: Revealed a 1.5 cm plaque with erythema and telangiectases on the left angle of the jaw. A 5-6 mm papule suspicious for basal cell carcinoma was seen on the right nasal bridge region. A previous surgical scar was present on the right lower eyelid without evidence of recurrence. Small actinic keratosis were also seen on the forehead and cheeks.

I feel that these two areas are suspicious for basal cell carcinoma. Biopsy will be performed and surgical excision will be arranged pending the biopsy report.

Diagnoses: 1. Plaque of left angle of jaw -- differential diagnosis to include basal cell carcinoma and hypertrophic actinic keratosis.
                  2. Basal cell carcinoma of right nasal bridge.

Plan: Arrangements will be made for a cutaneous biopsy with further treatment pending results.


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Edited Sample Report

Thank you for sending along this pleasant patient for my assessment. He presents for assessment of a lesion which has been present on the left forehead just superior to the eyebrow since birth. This has become more raised and papular over the past 1-2 years. No other symptoms have been noted and there is no past history of other significant skin disorders.

Exam: Revealed a well-circumscribed, 1.3 x 0.9 cm yellow plaque with slight follicular prominence on the left supraorbital forehead. The remainder of the cutaneous examination was unremarkable.

Clinical findings are consistent with nevus sebaceous. There is an associated 10-15% risk of transformation into basal cell carcinoma with this lesion and I feel that prophylactic excision is advisable. I have taken the liberty of referring the patient to Dr. D. Ward for consideration of this procedure.

Diagnosis: Nevus sebaceous of left forehead.

Plan: Arrangements will be made for plastic surgery referral for assessment of excision.

Edited Sample Report

Thank you for sending along this pleasant patient for my assessment. She has developed areas of pigmentation on the cheeks, upper lip and forehead regions for the past several years. This will darken during summer months. She will also notice comedones and acne pustules on the chin. She is not on any current treatment measures.

Exam: Revealed well-defined pigmentation of the central cheeks, lateral forehead and upper lip. Comedones and a few inflammatory papules were seen on the chin and jawline region.

She will start the above topical therapy with further review in two months.

Diagnoses: 1. Melasma.
                      2. Comedonal acne.

Plan: 1. 6% hydroquinone, ½% ascorbic acid in Tridesilon cream applied b.i.d. for melasma.
         2. Retisol-A 0.025% cream applied once daily for acne.
         3. Regular sun protection measures.

Edited Sample Report

Thank you for sending along this pleasant patient for my assessment. She presents for assessment of a lesion on the left extensor elbow which has been present for the past two years. This will occasionally become pruritic and irritated. There is no past history of other significant skin disorders and her general health is good.

Exam: Revealed a keratotic papule on the left extensor elbow. A benign compound nevus was seen on the left neck and the remainder of the cutaneous examination was unremarkable.

I believe this is a localized verruca and this was treated today with cryotherapy with further review on a p.r.n. basis.

Diagnosis: Symptomatic verruca of left elbow.

Plan: Liquid nitrogen cryotherapy.

Edited Sample Report

Thank you for asking me to see this girl for assessment of atopic dermatitis. This has been present since early childhood. She has previously been on topical therapies, although her mother is unsure as to which exact medications have been used. She will use emollients such as baby oil. Symptoms appear to worsen somewhat during the summer months. There is no previous history of respiratory atopy and her general health is good.

Exam: Revealed subacute dermatitis with erythema, scaling and lichenification affecting areas on the trunk and extremities and face. There did not appear to be evidence of secondary infection at present.

She will start the above treatment measures with further review in one month.

Diagnosis: Atopic dermatitis.

Plan: 1. 0.1% Celestoderm cream and ointment in equal parts applied b.i.d. to affected areas of body.
         2. Desocort cream applied b.i.d. to affected areas of face.
         3. Atarax, 10-20 mg q. h.s.


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Edited Sample Report

Thank you for sending along this patient with a history of chronic localized plaque psoriasis. He will develop areas on the scalp and lower extremities. Previous treatments have included topical steroids, tar,and Dovonex. He has not required ultraviolet or systemic therapies in the past.

Exam: Revealed localized plaques of psoriasis on the scalp as well as left lower leg.

He will start the above topical therapies with further review in one month.

Diagnosis: Localized plaque psoriasis.

Plan: 1. Valisone 0.1% lotion applied b.i.d. to affected areas of scalp.
         2. Micanol 1% cream applied as short contact therapy for localized plaques of left leg.

Edited Sample Report

Thank you for referring this patient to me. He presents for assessment of an ulcerated lesion on the left ear which has been present for the past several months. The patient uses Dettol for cleansing the area. There is no previous history of cutaneous carcinoma and he has Type III pigmentation of the skin. His general health is very good and he takes no regular medication.

Exam: Revealed an 8 mm, irregular, superficial ulcer of the superior aspect of the left pinna. No obvious underlying pathology was present. The remainder of the examination was unremarkable.

I believe this is an area of traumatic ulceration and slow healing, secondary to factors such as dessication and the use of Dettol. A biopsy specimen was obtained to rule out an underlying neoplasm and he was started on topical therapy with Fucidin ointment with further review in two weeks.


Diagnosis: Traumatic ulceration of left ear. Differential diagnosis to include ulcerated basal cell carcinoma.

Plan: 1. A cutaneous biopsy specimen was obtained.
         2. Fucidin ointment applied t.i.d.

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