Sample Transcribed Reports:

Dermatology . . . Page 1

These reports are samples of basic clinical evaluations of patients seen by a dermatologist. The sample reports have been checked for accuracy in spelling, but please keep in mind nobody's perfect, and we do appreciate any notification of errors. These sample medical reports may also include some styles or report formats that are unusual, and if so, this would be due to the preference of the dictating physician.

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Edited Sample Report

Thank you for sending along this pleasant patient for my assessment. He presents for assessment of a pigmented lesion developing on the trunk and extremities. There is no past history of cutaneous carcinoma or dysplastic nevi,although he states he has had previous nevi excised. He has Type III pigmentation of the skin and had significant sun exposure in the past. His general health is good and his only current regular medication is thyroid replacement.

Exam: Revealed several seborrheic keratoses and lentigines on the trunk and upper extremities. A small actinic keratosis was seen on the right forehead. Erythematous lichenoid keratoses were present on the left lower leg.

Treatment was given today with cryotherapy. There were no suspicious lesions at present and he was advised to return for review on a p.r.n. basis.

Diagnoses: 1. Actinic keratosis of right forehead.
                    2. Lichenoid keratoses of left lower leg.

Plan: Liquid nitrogen cryotherapy.

Edited Sample Report

Thank you for sending along this pleasant patient for my assessment. She presents for assessment of acne symptoms.She will develop papules and pustules as well as the occasional inflammatory nodule. She has previous been on systemic antibiotic therapy including erythromycin which she took for up to a two-month duration. She was also on topical vitamin A acid but found this to be too irritating. Her menstrual cycles are regular and she is on the oral contraceptive pill. She also gives a history of easy flushing and blushing of the face.

Exam: Revealed papules and pustules distributed on the forehead, cheeks and chin. Only a slight comedonal component was present.

I believe this is a combination of both rosacea and acne vulgaris. She will start on the above treatment measures with further review in two months.

Diagnosis: Rosacea and acne vulgaris.

Plan: 1. Doxycycline, 100 mg daily.
         2. 1 percent hydrocortisone, 1 percent clindamycin, 1 percent metronidazole in Complex 15 lotion applied b.i.d.

Edited Sample Report

Thank you for asking me to see this patient in re-referral. She was last assessed in February and at that time, the area on the lower right leg had shown complete healing. I initially assessed her in November of 1997, and felt that inflammatory reaction may have represented an infected insect bite.

Exam: Revealed a 2.5 x 1.5 cm mildly atrophic scar with post-inflammatory hyperpigmentation. There was no evidence of an active inflammatory process.

I feel that this represents post-inflammatory changes with scarring and hyperpigmentation. No specific treatment measures were necessary.

Diagnosis: Atrophic scar and post-inflammatory hyperpigmentation of right lower leg.

Plan: No treatment measures necessary.

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