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Dermatology . . . Page 5


 

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Edited Sample Report

Thank you for referring this patient to me. He has a history of a lesion affecting the right anterior lower leg for the past eight months. This occasionally becomes tender and has also apparently shown drainage in the past. He denies a history of pruritus or excoriation. There is no past history of other significant skin disorders and his general health is good.

Exam: Revealed a small pustule with surrounding post-inflammatory hyperpigmentation on the right anterior leg. The pustule was drained and a swab for wound culture was obtained. There did not appear to be any other underlying process at present. The remainder of the cutaneous examination was unremarkable.

I believe this is a small furuncle or possibly a foreign body reaction. He will start on simple topical therapy with further review in two weeks.

Diagnosis: Pyoderma of right leg -- differential diagnosis to include furuncle and foreign body reaction.

Plan: Warm compresses followed by Bactroban ointment t.i.d.

Edited Sample Report

Thank you for asking me to see this pleasant patient and for your referral note. She presents for assessment of symptoms of hair-shedding and thinning noticeable over the past one year. She has not developed any areas of focal alopecia. Her menstrual cycles are regular and there is no history of significant acne or hirsutism. Her general health is good, although she has a history of previous schizophrenia and is on long-term Haldol, 1mg daily. Review of the family history is positive for androgenetic alopecia.

Exam: Revealed an increased frontal part-width and mild thinning of the frontal to vertex region of the scalp. A gentle hair-pull test showed 1-3 telogen hairs per pull. The remainder of the examination was unremarkable.

I feel that this represents early androgenetic alopecia. Screening investigations including ferritin and TSH have been performed and are within normal limits. I do not feel that any further investigations are necessary at present. Topical minoxidil therapy was discussed and she will start on 5% solution with further review in six months.

Diagnosis: Androgenetic alopecia.

Plan: 5% minoxidil solution applied b.i.d.

Thank you for referring this patient to me. He has a history of a lesion affecting the right anterior lower leg for the past eight months. This occasionally becomes tender and has also apparently shown drainage in the past. He denies a history of pruritus or excoriation. There is no past history of other significant skin disorders and his general health is good.

Exam: Revealed a small pustule with surrounding post-inflammatory hyperpigmentation on the right anterior leg. The pustule was drained and a swab for wound culture was obtained. There did not appear to be any other underlying process at present. The remainder of the cutaneous examination was unremarkable.

I believe this is a small furuncle or possibly a foreign body reaction. He will start on simple topical therapy with further review in two weeks.

Diagnosis: Pyoderma of right leg -- differential diagnosis to include furuncle and foreign body reaction.

Plan: Warm compresses followed by Bactroban ointment t.i.d.


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Edited Sample Report

Thank you for asking me to see this pleasant patient and for your referral note and copies of previous investigations and consultations. She presents for assessment of multiple hypopigmented patches developing on the face, shoulders, and arms. She has a history of dry skin and apparently had episodes of dermatitis in earlier childhood. She will occasionally develop symptoms of pruritus and scaling. She has been on previous therapy with Topicort cream and will also use Prevex cream as an emollient to the lips. There is also a history of mild facial hirsutism but the patient did not present this as a concern today. Her menstrual cycles are irregular with oligomenorrhea. It should also be noted that she has had a weight gain of approximately 30 pounds over the past one year. Review of the family history is positive for atopy.

Exam: Revealed moderately-well-defined, hypopigmented, slightly scaling plaques on the face, shoulders,and arms. General xerosis of the skin was present. Thickening and hyperpigmentation of the neck and axillary folds was present, consistent with acanthosis nigricans. Mild hirsutism was evident on the lip and jawline regions.

I feel that the hypopigmented patches represent pityriasis alba. This represents post-inflammatory hypopigmentation, secondary to dermatitis which is usually seen in an atopic setting. She also has findings of mild acanthosis nigricans which I feel is likely secondary to her past weight gain. I did not feel that the mild hirsutism represented an endocrine abnormality and she has had previous screening investigations including DHEAS and testosterone levels which were normal. She was started on topical therapy for treatment of dermatitis with further review in one month.

Diagnoses: 1. Pityriasis alba -- post-inflammatory hypopigmentation.
                      2. Acanthosis nigricans, secondary to weight gain and obesity.

Plan: 1. Regular use of emolients.
         2. Elocom 0.1% cream applied once daily to active areas of dermatitis.


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Edited Sample Report

Thank you for asking me to see this patient. She gives a history of persistent hair-shedding for the past 1½ years. She also notices loss of hair volume and increased part-width of the hair. Her menstrual cycles are regular and she does not have a history of significant illnesses over the past one year. However, she apparently has been diagnosed with borderline hypothyroidism and is on a thyroid supplement at present. She statest hat a TSH level was checked two months ago. Review of the family history shows male pattern alopecia affecting her father and brother.

On examination, there was no visible thinning of the scalp hair evident and the frontal hairline was well preserved. There was no evidence of virilization. A gentle hair-pull test showed slightly increased telogen hairs, with 3-5 hairs per pull from both the frontal and occipital regions of the scalp.

I believe this is a process of telogen effluvium. This may be secondary to underlying thyroid abnormality and a repeat TSH will be performed. The differential diagnosis would include idiopathic chronic telogen effluvium as well as early androgenetic alopecia. Topical minoxidil therapy can be considered for both of these conditions pending results of laboratory investigations. She will return for further review in three weeks.

Diagnosis: Telogen effluvium.

Plan: 1. TSH, ferritin, testosterone, and DHEAS levels to be obtained.
         2. Topical minoxidil therapy in reserve.

Edited Sample Report

Thank you for asking me to see this pleasant patient and for your helpful referral note. She presents for assessment of a persistent dermatosis affecting the central chest and inframammary fold regions for the past one year. She is not on any current treatment measures.

Exam: Revealed well-defined, red-brown plaques. A potassium hydroxide examination showed the presence of pityrosporum hyphae.

She was started on topical therapy for localized tinea versicolor with further review on a p.r.n. basis.

Diagnosis: Tinea versicolor of chest.

Plan: Canesten cream applied b.i.d. x 2 weeks.

Edited Sample Report

Thank you for referring this patient to me. She presented one month ago with an inflammatory nodule of the nasal tip region. This has subsequently spontaneously resolved. She will also develop occasional acne pustules as well as comedones.

Exam: Revealed post-inflammatory erythema of the nasal tip. Comedonal and mildly inflammatory acne was seen on the forehead and nose.

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

Diagnosis: Acne vulgaris.

Plan: Retisol-A 0.025% cream applied once daily.

Edited Sample Report

Thank you for sending along this patient who gives a history of ongoing symptoms of pustules affecting the scalp and face over the past several years. He has previously been treated with systemic minocycline and has also used topical erythromycin in the past. His general health is good and there is no past history of other significant skin disorders. His only current long-term medication is Vasotec.

Exam: Revealed follicular pustules affecting the temporal and occipital scalp regions. Inflammatory pustules and furuncles were also seen on the cheeks and temple regions. No comedones were present and there was no evidence of scarring affecting the scalp.

I believe this is a process of ongoing superficial folliculitis and furunculosis. A swab for culture was taken and he was started on the above systemic and topical therapy. Treatment for staph aureus carriage may beconsidered in the future if symptoms continue to recur. He will return for further review in two weeks.

Diagnosis: Superficial folliculitis and furunculosis of scalp and face.

Plan: 1. Keflex, 500 mg b.i.d.
         2. 1% clindamycin in Dilusol lotion applied b.i.d.


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