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MEDICAL SPECIALTY DERMATOLOGY

Sample Name: Acne - SOAP

DESCRIPTION: Acne with folliculitis.

(Medical Transcription Sample Report)

SUBJECTIVE: The patient is a 49-year-old white female, established patient to Dermatology, last seen in the office on 08/10/2004. She comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest, stomach, neck, and back. On examination, this is a flaring of her acne with small folliculitis lesions. The patient has been taking amoxicillin 500 mg b.i.d. and using Tazorac cream 0.1, and her face is doing well, but she has been out of her medicine now for three days also. She has also been getting photofacials at Healing Waters and was wondering about what we could offer as far as cosmetic procedures and skin care products, etc. The patient is married. She is a secretary.

FAMILY, SOCIAL, AND ALLERGY HISTORY: She has hay fever, eczema, sinus, and hives. She has no melanoma or skin cancers or psoriasis. Her mother had oral cancer. The patient is a nonsmoker. No blood tests. Had some sunburn in the past. She is on benzoyl peroxide and Daypro.

CURRENT MEDICATIONS: Lexapro, Effexor, Ditropan, aspirin, vitamins.

PHYSICAL EXAMINATION: The patient is well developed, appears stated age. Overall health is good. She has a couple of acne lesions, one on her face and neck but there are a lot of small folliculitis-like lesions on her abdomen, chest, and back.

IMPRESSION: Acne with folliculitis.

TREATMENT:

1. Discussed condition and treatment with the patient.

2. Continue the amoxicillin 500 mg two at bedtime.

3. Add Septra DS every morning with extra water.

4. Continue the Tazorac cream 0.1; it is okay to use on back and chest also.

5. Referred to ABC clinic for an aesthetic consult. Return in two months for followup evaluation of her acne.

Sample Name: Acne Vulgaris

Description: A simple note on Acne Vulgaris.

(Medical Transcription Sample Report)

ACNE VULGARIS, commonly referred to as just acne, is a chronic inflammation of the skin that occurs most often during adolescence but can occur off and on throughout life. The skin eruptions most often appear on the face, chest, back and upper arms and are more common in males than females.

SIGNS AND SYMPTOMS:

* Blackheads the size of a pinhead.

* Whiteheads similar to blackheads.

* Pustules - lesions filled with pus.

* Redness and inflamed skin.

* Cysts - large, firm swollen lesions in severe acne.

* Abscess - infected lesion that is swollen, tender, inflamed, filled with pus, also seen in severe acne.

CAUSES:

Oil glands in the skin become plugged for reasons unknown but during adolescence, sex-hormone changes play some role. When oil backs up in the plugged gland, a bacteria normally present on skin causes an infection. Acne is NOT caused by foods, uncleanliness or masturbation. Cleaning the skin can decrease its severity but sexual activity has no effect on it. A family history of acne can indicate if an individual will get acne and how severe it might be. Currently, acne can't be prevented.

ACNE CAN BE BROUGHT ON OR MADE WORSE BY:

* Hot or cold temperatures.

* Emotional stress.

* Oily skin.

* Endocrine (hormone) disorder.

* Drugs such as cortisones, male hormones, or oral contraceptives.

* Some cosmetics.

* Food sensitivities. Again, foods do not cause acne but some certain ones may make it worse. To discover any food sensitivities, eliminate suspicious foods from your diet and then start eating them again one at a time. If acne worsens 2-3 days after consumption, then avoid this food. Acne usually improves in summer so some foods may be tolerated in summer that can't be eaten in winter.

TREATMENT:

* Most cases of acne respond well to treatment and will likely disappear once adolescence is over. Even with adequate treatment, acne will tend to flare up from time to time and sometimes permanent facial scars or pitting of the skin may occur.

* If your skin is oily, gently clean face with a fresh, clean wash cloth using unscented soap for 3- 5 minutes; an antibacterial soap may work better. A previously used wet washcloth will harbor bacteria. Don't aggressively scrub tender lesions as this may spread infection; be gentle. Rinse the soap off for a good 1-2 minutes. Dry face carefully with a clean towel and use an astringent such as rubbing alcohol that will remove the skin oil.

OTHER TIPS THAT MAY HELP ACNE:

* Shampoo hair at least twice a week. Keep hair off of face even while sleeping as hair can spread oil and bacteria. If you have dandruff, use a dandruff shampoo. Avoid cream hair rinses.

* Wash sweat and skin oil off as soon as possible after sweating and exercising.

* Use thinner, water-based cosmetics instead of the heavier oil-based ones.

* Avoid skin moisturizers unless recommended by your doctor.

* Do not squeeze, pick, rub or scratch your skin or the acne lesions. This may damage the skin causing scarring and delay healing of acne. Only a doctor should remove blackheads.

* Keep from resting face on hands while reading, studying or watching TV.

* Try to avoid pressing the phone receiver on you chin while talking on the phone.

* Ultraviolet light may be a treatment recommended by your doctor but this is by no means a license to sunbathe! Don't use the sun to treat acne.

* Dermabrasion may be another option to treat acne scars. This is a type of cosmetic surgery to help remove unsightly scars.

MEDICATIONS THAT MAY BE PRESCRIBED TO HELP ACNE INCLUDE:

* Oral or topical antibiotics.

* Cortisone injections into acne lesions.

* Oral contraceptives.

* Tretinoin, which may increase sun sensitivity and excessive dryness, is not recommended during pregnancy.

* Accutane (isotretinoin) is a powerful drug to treat acne but causes birth defects. A woman taking this drug

must be on two types of birth control and have negative pregnancy tests. This drug also increases sun

sensitivity. Other more serious side effects can occur and your doctor will discuss those with you if Accutane is to be prescribed.

TETRACYCLINE:

Tetracycline is a very safe antibiotic. It is not related to penicillin and an allergy to it is unusual. There are several potential side effects:

1. Tetracycline can cause nausea or heartburn.

2. Tetracycline can cause vaginitis.

3. Tetracycline can cause excessive sun burn.

CAUTIONS ON TETRACYCLINE:

1. Do not take Tetracycline with milk or milk products (ice cream, cheese, yogurt, etc.). This will cancel out the Tetracycline. Separate the Tetracycline from these products by one and one-half hours before and after each capsule. Do have a small amount of non milk-containing food in your stomach first to prevent nausea.

2. Do not take Tetracycline if you are pregnant.

3. Do not take Tetracycline if you are taking birth control pills unless specifically instructed to do so.

4. If at the beach or skiing in the sun, use an effective sunblock (SPF-15 or greater) to prevent burning.

Sample Name: Acne Vulgaris - H&P

Description: Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris

(Medical Transcription Sample Report)

CHIEF COMPLAINT (1/1): This 19 year old female presents today complaining of acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use. Location: She indicates the problem location is the chin, right temple and left temple locally. Severity: Severity of condition is worsening.

Menses: Onset: 13 years old. Interval: 22-27 days. Duration: 4-6 days. Flow: light. Complications: none.

ALLERGIES: Patient admits allergies to penicillin resulting in difficulty breathing.

MEDICATION HISTORY: Patient is currently taking Alesse-28, 20 mcg-0.10 mg tablet usage started on 08/07/2001 medication was prescribed by Obstetrician-Gynecologist A.

PAST MEDICAL HISTORY: Female Reproductive Hx: (+) birth control pill use, Childhood Illnesses: (+) chickenpox, (+) measles.

PAST SURGICAL HISTORY: No previous surgeries.

FAMILY HISTORY: Patient admits a family history of anxiety, stress disorder associated with mother.

SOCIAL HISTORY: Patient admits caffeine use She consumes 3-5 servings per day, Patient admits alcohol use Drinking is described as social, Patient admits good diet habits, Patient admits exercising regularly, Patient denies STD history.

REVIEW OF SYSTEMS: Integumentary: (+) periodic reddening of face, (+) acne problems, Allergic /

Immunologic: (-) allergic or immunologic symptoms, Constitutional Symptoms: (-) constitutional symptoms

such as fever, headache, nausea, dizziness.

PHYSICAL EXAM: Patient is a 19 year old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus. Skin: Examination of scalp shows no abnormalities. Hair growth and distribution is normal. Inspection of skin outside of affected area reveals no abnormalities. Palpation of skin shows no abnormalities. Inspection of eccrine and apocrine glands shows no evidence of hyperidrosis, chromidrosis or bromhidrosis. Face shows keratotic papule.

IMPRESSION: Acne vulgaris.

PLAN: Recommended treatment is antibiotic therapy. Patient received extensive counseling about acne. She understands acne treatment is usually long-term. Return to clinic in 4 week (s).

PATIENT INSTRUCTIONS: Patient received literature regarding acne vulgaris. Discussed with the patient the prescription for Tetracycline and handed out information regarding the side effects and the proper method of ingestion.

PRESCRIPTIONS: Tetracycline Dosage: 250 mg capsule Sig: BID Dispense: 60 Refills: 0 Allow Generic: Yes

Sample Name: Atopic Eczema

Description: 1+ year, black female for initial evaluation of a lifelong history of atopic eczema.

(Medical Transcription Sample Report)

SUBJECTIVE: This 1+ year, black female, new patient in dermatology, sent in for consult from ABC Practice for initial evaluation of a lifelong history of atopic eczema. The patient’s mom is from Tanzania. The patient has been treated with Elidel cream b.i.d. for six months but apparently this has stopped working now and it seems to make her more dry and plus she has been using some Johnson's Baby Oil on her. The patient is a well-developed baby. Appears stated age. Overall health is good.

FAMILY, SOCIAL, AND ALLERGY HISTORY: The patient has eczema and a positive atopic family history. No psoriasis. No known drug allergies.

CURRENT MEDICATIONS: None.

PHYSICAL EXAMINATION: The patient has eczematous changes today on her face, trunk, and extremities.

IMPRESSION: Atopic eczema.

TREATMENT:

1. Discussed condition and treatment with Mom.

2. Continue bathing twice a week.

3. Discontinue hot soapy water.

4. Discontinue Elidel for now.

5. Add Aristocort cream 0.25%, Polysporin ointment, Aquaphor b.i.d. and p.r.n. itch. We will see her in one month if not better otherwise on a p.r.n. basis. Send a letter to ABC Practice program.

Sample Name: Biopsy - Actinic Keratosis

Description: Excisional biopsy of actinic keratosis and skin nevus, two-layer and one-layer plastic closures,

(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES:

1. Left chest actinic keratosis, 2 cm.

2. Left medial chest actinic keratosis, 1 cm.

3. Left shoulder actinic keratosis, 1 cm.

POSTOPERATIVE DIAGNOSES:

1. Left chest actinic keratosis, 2 cm.

2. Left medial chest actinic keratosis, 1 cm.

3. Left shoulder actinic keratosis, 1 cm.

TITLE OF PROCEDURES:

1. Excisional biopsy of left chest 2 cm actinic keratosis.

2. Two-layer plastic closure.

3. Excisional biopsy of left chest medial actinic keratosis 1 cm with one-layer plastic closure.

4. Excisional biopsy of left should skin nevus, 1 cm, one-layer plastic closure.

ANESTHESIA: Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 6 mL.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None.

PROCEDURE: All areas were prepped, draped, and localized in the usual manner. Afterwards, elliptical incisions were placed with a #15-blade scalpel and curved iris scissors and small bishop forceps were used for the dissection of the skin lesions. After all were removed, they were closed with one-layer technique for the shoulder and medial lesion, and the larger left chest lesion was closed with two-layer closure using Monocryl 5-0 for subcuticular closure and 5-0 nylon for skin closure. She tolerated this procedure very well, and postoperative care instructions were provided. She will follow up next week for suture removal. Of note, she had an episode of hemoptysis, which could not be explained prompting an emergency room visit, and I discussed if this continues we may wish to perform a fiberoptic laryngoscopy examination and possible further workup if a diagnosis cannot be made.

Sample Name: Biopsy - Skin Nevus

Description: Excisional biopsy of skin nevus and two-layer plastic closure. Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.

(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES:

1. Left back skin nevus 2 cm.

2. Right mid back skin nevus 1 cm.

3. Right shoulder skin nevus 2.5 cm.

4. Actinic keratosis left lateral nasal skin 2.5 cm.

POSTOPERATIVE DIAGNOSES:

1. Left back skin nevus 2 cm.

2. Right mid back skin nevus 1 cm.

3. Right shoulder skin nevus 2.5 cm.

4. Actinic keratosis, left lateral nasal skin, 2.5 cm.

PATHOLOGY: Pending.

TITLE OF PROCEDURES:

1. Excisional biopsy of left back skin nevus 2 cm, two layer plastic closure.

2. Excisional biopsy of mid back skin nevus 1 cm, one-layer plastic closure.

3. Excisional biopsy of right shoulder skin nevus 2.5 cm, one-layer plastic closure.

4. Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.

ANESTHESIA: Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 8 mL.

BLOOD LOSS: Minimal.

COMPLICATIONS: None.

PROCEDURE: Consent was obtained. The areas were prepped and draped and localized in the usual manner. First attention was drawn to the left back. An elliptical incision was made with a 15-blade scalpel. The skin ellipse was then grasped with a Bishop forceps and curved Iris scissors were used to dissect the skin ellipse. After dissection, the skin was undermined. Radiofrequency cautery was used for hemostasis, and using a 5-0 undyed Vicryl skin was closed in the subcuticular plane and then skin was closed at the level of the skin with 4-0 nylon interrupted suture.

Next, attention was drawn to the mid back. The skin was incised with a vertical elliptical incision with a 15-blade scalpel and then the mass was grasped with a Bishop forceps and excised with curved Iris scissors. Afterwards, the skin was approximated using 4-0 nylon interrupted sutures. Next, attention was drawn to the shoulder lesion. It was previously marked and a 15-blade scalpel was used to make an elliptical incision into the skin.

Next, the skin was grasped with a small Bishop forceps and curved Iris scissors were used to dissect the skin ellipse and removed the skin. The skin was undermined with the curved Iris scissors and then radio frequency treatment was used for hemostasis.

Next, subcuticular plain was closed with 5-0 undyed Vicryl interrupted suture. Skin was closed with 4-0 nylon suture, interrupted. Lastly, trichloroacetic acid chemical peel treatment to the left lateral nasal skin was performed. Please refer to separate operative report for details. The patient tolerated this procedure very well and we will follow up next week for postoperative re-evaluation or sooner if there are any problems.

Keywords: dermatology, mid back skin nevus, actinic keratosis, trichloroacetic acid treatment, bishop forceps, skin nevus, plastic closure, curved iris, iris scissors, nasal skin, nevus, biopsy, nasal, forceps,

Sample Name: Burn - Consult

Description: First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.

(Medical Transcription Sample Report)

CHIEF COMPLAINT: Burn, right arm.

HISTORY OF PRESENT ILLNESS: This is a Workers' Compensation injury. This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect. He has had it cooled, and presents with his friend to the Emergency Department for care.

PAST MEDICAL HISTORY: Noncontributory.

MEDICATIONS: None.

ALLERGIES: None.

PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished 21-year-old male adult who is appropriate and cooperative. His only injury is to the right upper extremity. There are first and second degree burns on the right forearm, ranging from the elbow to the wrist. Second degree areas with blistering are scattered through the medial aspect of the forearm. There is no circumferential burn, and I see no areas of deeper burn. The patient moves his hands well. Pulses are good. Circulation to the hand is fine.

FINAL DIAGNOSIS:

1. First-degree and second-degree burns, right arm secondary to hot oil spill.

2. Workers' Compensation industrial injury.

TREATMENT: The wound is cooled and cleansed with soaking in antiseptic solution. The patient was ordered Demerol 50 mg IM for pain, but he refused and did not want pain medication. A burn dressing is applied with Neosporin ointment. The patient is given Tylenol No. 3, tabs #4, to take home with him and take one or two every four hours p.r.n. for pain. He is to return tomorrow for a dressing change. Tetanus immunization is up to date. Preprinted instructions are given. Workers' Compensation first report and work status report are completed.

DISPOSITION: Home.

Keywords: dermatology, burn, workers' compensation industrial injury, workers' compensation, degree,

Sample Name: Buttock Abscess

Description: Left buttock abscess, status post incision and drainage. Recommended some local wound care

(Medical Transcription Sample Report)

CHIEF COMPLAINT: Buttock abscess.

HISTORY OF PRESENT ILLNESS: This patient is a 24-year-old African-American female who presented to the hospital with buttock pain. She started off with a little pimple on the buttock. She was soaking it at home without any improvement. She came to the hospital on the first. The patient underwent incision and drainage in the emergency department. She was admitted to the hospitalist service with elevated blood sugars. She has had positive blood cultures. Surgery is consulted today for evaluation.

PAST MEDICAL HISTORY: Diabetes type II, poorly controlled, high cholesterol.

PAST SURGICAL HISTORY: C-section and D&C.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

MEDICATIONS: Insulin, metformin, Glucotrol, and Lipitor.

FAMILY HISTORY: Diabetes, hypertension, stroke, Parkinson disease, and heart disease.

REVIEW OF SYSTEMS: Significant for pain in the buttock. Otherwise negative.

PHYSICAL EXAMINATION:

GENERAL: This is an overweight African-American female not in any distress.

VITAL SIGNS: She has been afebrile since admission. Vital signs have been stable. Blood sugars have been in the 200 range.

HEENT: Normal to inspection.

NECK: No bruits or adenopathy.

LUNGS: Clear to auscultation.

CV: Regular rate and rhythm.

ABDOMEN: Protuberant, soft, and nontender.

EXTREMITIES: No clubbing, cyanosis or edema.

RECTAL EXAM: The patient has a drained abscess on the buttock cheek. There is some serosanguineous drainage. There is no longer any purulent drainage. The wound appears relatively clean. I do not see a lot of erythema.

ASSESSMENT AND PLAN: Left buttock abscess, status post incision and drainage. I do not believe surgical intervention is warranted. I have recommended some local wound care. Please see orders for details.

Sample Name: Condyloma Cauterization

Description: Cauterization of peri and intra-anal condylomas. Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata.

(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Extensive perianal and intra-anal condyloma.

POSTOPERATIVE DIAGNOSIS: Extensive perianal and intra-anal condyloma.

PROCEDURE PERFORMED: Cauterization of peri and intra-anal condylomas.

ANESTHESIA: IV sedation and local.

SPECIMEN: Multiple condylomas were sent to pathology.

ESTIMATED BLOOD LOSS: 10 cc.

BRIEF HISTORY: This is a 22-year-old female, who presented to the office complaining of condylomas she had noted in her anal region. She has noticed approximately three to four weeks ago. She denies any pain but does state that there is some itching. No other symptoms associated.

GROSS FINDINGS: We found multiple extensive perianal and intra-anal condylomas, which are likely represent condyloma acuminata.

PROCEDURE: After risks, benefits and complications were explained to the patient and a verbal consent was obtained, the patient was taken to the operating room. After the area was prepped and draped, a local anesthesia was achieved with Marcaine. Bovie electrocautery was then used to remove the condylomas taking care to achieve meticulous hemostasis throughout the course of the procedure. The condylomas were removed 350 degrees from the perianal and intra-anal regions. After all visible condylomas were removed, the area was again washed with acetic acid solution. Any residual condylomas were then cauterized at this time. The area was then examined again for any residual bleeding and there was none.

DISPOSITION: The patient was taken to Recovery in stable condition. She will be sent home with prescriptions for a topical lidocaine and Vicodin. She will be instructed to do sitz bath b.i.d., and post-bowel movement. She will follow up in the office next week.

Keywords: dermatology, intra-anal, perianal, acuminata, cauterization, condyloma, anal,

Sample Name: Dermatitis - SOAP

Description: Hand dermatitis.

(Medical Transcription Sample Report)

SUBJECTIVE: This is a 29-year-old Vietnamese female, established patient of dermatology, last seen in our office on 07/13/04. She comes in today as a referral from ABC, D.O. for a reevaluation of her hand eczema. I have treated her with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion, and wash her hands in Cetaphil cleansing lotion. She comes in today for reevaluation because she is flaring. Her hands are very dry, they are cracked, she has been washing with soap. She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin. She has been wearing some gloves also apparently. The patient is single. She is unemployed.

FAMILY, SOCIAL, AND ALLERGY HISTORY: The patient has asthma, sinus, hives, and history of psoriasis. No known drug allergies.

MEDICATIONS: The patient is a nonsmoker. No bad sunburns or blood pressure problems in the past.

CURRENT MEDICATIONS: Claritin and Zyrtec p.r.n.

PHYSICAL EXAMINATION: The patient has very dry, cracked hands bilaterally.

IMPRESSION: Hand dermatitis.

TREATMENT:

1. Discussed further treatment with the patient and her interpreter.

2. Apply Aristocort ointment 0.1% and equal part of Polysporin ointment t.i.d. and p.r.n. itch.

3. Discontinue hot soapy water and wash her hands with Cetaphil cleansing lotion.

4. Keflex 500 mg b.i.d. times two weeks with one refill. Return in one month if not better; otherwise, on a p.r.n. basis and send Dr. XYZ a letter on this office visit.

Keywords: dermatology, cetaphil cleansing lotion, hand dermatitis, aristocort, wash, ointment, hand, lotion, dermatitis,

Sample Name: Epidermal Autograft

Description: A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings. Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.

(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.

POSTOPERATIVE DIAGNOSIS: A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.

PROCEDURES PERFORMED:

1. Epidermal autograft on Integra to the back (3520 cm2).

2. Application of allograft to areas of the lost Integra, not grafted on the back (970 cm2).

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: Approximately 50 cc.

BLOOD PRODUCTS RECEIVED: One unit of packed red blood cells.

COMPLICATIONS: None.

INDICATIONS: The patient is a 26-year-old male, who sustained a 60% total body surface area flame burn involving the head, face, neck, chest, abdomen, back, bilateral upper extremities, hands, and bilateral lower extremities. He has previously undergone total burn excision with placement of Integra and an initial round of epidermal autografting to the bilateral upper extremities and hands. His donor sites have healed particularly over his buttocks and he returns for a second round of epidermal autografting over the Integra on his back utilizing the buttock donor sites, the extent they will provide coverage.

OPERATIVE FINDINGS:

1. Variable take of Integra, particularly centrally and inferiorly on the back. A fair amount of lost Integra over the upper back and shoulders.

2. No evidence of infection.

3. Healthy viable wound beds prior to grafting.

PROCEDURE IN DETAIL: The patient was brought to the operating room and positioned supine. General endotracheal anesthesia was uneventfully induced and an appropriate time out was performed. He was then repositioned prone and perioperative IV antibiotics were administered. He was prepped and draped in the usual sterile manner. All staples were removed from the Integra and the adherent areas of Silastic were removed. The entire wound bed was further prepped with scrub brushes and more Betadine followed by a sulfamylon solution. Hemostasis of the wound bed was ensured using epinephrine-soaked Telfa pads. Following dermal tumescence of the buttocks, epidermal autografts were harvested 8 one-thousandths of an inch using the air Zimmer dermatome. These grafts were passed to the back table where they were meshed 3:1. The donor sites were hemostased using epinephrine-soaked Telfa and lap pads. Once all the grafts were meshed, we brought them back up onto the field, positioned them over the wounds beginning inferiorly and moving cephalad where we had best areas of Integra engraftment. We were happy with the lie of the grafts and they were stapled into place. The grafts were then overlaid with Conformant 2, which was also stapled into place. Utilizing all of his buttocks skin, we did not have enough to cover his entire back, so we elected to apply allograft to the cephalad and a few areas on his flanks where we had had poor Integra engraftment. Allograft was thawed and meshed 1:1. It was then brought up onto the field, trimmed to fit and stapled into place over the wound. Once the entirety of the posterior wounds on his back were covered out with epidermal autograft or allograft sulfamylon soaked dressings were applied. Donor sites on his buttocks were dressed in Acticoat and secured with staples. He was then repositioned supine and extubated in the operating room having tolerated the procedure without any apparent complications. He was transported to PACU in stable condition.

Keywords: dermatology, flame burns, body surface area, epidermal autograft, autograft, integra, integra engraftment, wound, grafts, epidermal, allograft,

Sample Name: Erythema Nodosum - Consult

DESCRIPTION: The patient presents for a followup for history of erythema nodosum.

(Medical Transcription Sample Report)

REASON FOR VISIT: The patient presents for a followup for history of erythema nodosum.

HISTORY OF PRESENT ILLNESS: This is a 25-year-old woman who is attending psychology classes. She was diagnosed with presumptive erythema nodosum in 2004 based on a biopsy consistent with erythema nodosum, but not entirely specific back in Netherlands. At that point, she had undergone workup which was extensive for secondary diseases associated with erythema nodosum. Part of her workup included a colonoscopy. The findings were equivocal characterizes not clearly abnormal biopsies of the terminal ileum.

The skin biopsy, in particular, mentions some fibrosis, basal proliferation, and inflammatory cells in the subcutis.

Prior to the onset of her erythema nodosum, she had a tibia-fibula fracture several years before on the right, which was not temporarily associated with the skin lesions, which are present in both legs anyway. Even, a jaw cosmetic surgery she underwent was long before she started developing her skin lesions. She was seen in our clinic and by Dermatology on several occasions. Apart from the first couple of visits when she presented stating a recurrent skin rash with a description suggestive of erythema nodosum in the lower extremities and ankle and there is discomfort pointing towards a possible inflammatory arthritis and an initial high sed rate of above 110 with an increased CRP. In the following visits, no evident abnormality has been detected. In the first visit, here some MTP discomfort detected. It was thought that erythema nodosum may be present. However, the evaluation of Dermatology did not concur and it was thought that the patient had venous stasis, which could be related to her prior fracture. When she was initially seen here, a suspicion of IBD, sarcoid inflammatory arthropathy, and lupus was raised. She had an equivocal rheumatoid fracture, but her CCP was negative. She had an ANA, which was positive at 1:40 with a speckled pattern persistently, but the rest of the lupus serologies including double-stranded DNA, RNP, Smith, Ro, La were negative. Her cardiolipin panel antibodies were negative as well. We followed the IgM, IgG, and IgA being less than 10. However, she did have a beta-2 glycoprotein 1 or an RVVT tested and this may be important since she has a livedo pattern. It was thought that the onset of lupus may be the case. It was thought that rheumatoid arthritis could not be the case since it is not associated with erythema nodosum. For the fear of possible lymphoma, she underwent CT of the chest, abdomen, and pelvis. It was done also in order to rule out sarcoid and the result was unremarkable. Based on some changes in her bowel habits and evidence of B12 deficiency with a high methylmalonic and high homocystine levels along with a low normal B12 in addition to iron studies consistent with iron deficiency and an initially low MCV, the possibility of inflammatory bowel disease was employed. The patient underwent an initially unrevealing colonoscopy and a capsule endoscopy, which was normal. A second colonoscopy was done recently and microscopically no evidence of inflammatory bowel disease was seen. However, eosinophil aggregations were noted in microscopy and this was told to be consistent with an allergic reaction or an emerging Crohn disease and I will need to discuss with Gastroenterology what is the significance of that. Her possible B12 deficiency and iron deficiency were never addressed during her stay here in the United States.

In the initial appointment, she was placed on prednisone 40 mg, which was gradually titrated down this led to an exacerbation of her acne. We decided to take her off prednisone due to adverse effects and start her on colchicine 0.6 mg daily. While this kept things under control with the inflammatory markers being positive and no overt episodes of erythema nodosum, the patient still complains for sensitivity with less suspicious skin rash in the lower extremities and occasional ankle swelling and pain. She was reevaluated by Dermatology for that and no evidence of erythema nodosum was felt to be present. Out plan was to proceed with a DEXA scan, at some point check a vitamin D level, and order vitamin D and calcium over the counter for bone protection purposes. However, the later was deferred until we have resolved the situation and find out what is the underlying cause of her disease.

Her past medical history apart from the tibia-fibular fracture and the jaw cosmetic surgery is significant for varicella and mononucleosis.

Her physical examination had shown consistently diffuse periarticular ankle edema and also venous stasis changes at least until I took over her care last August. I have not been able to detect any erythema nodosum, however, a livedo pattern has been detected consistently. She also has evidence of acne, which does not seem to be present at the moment. She also was found to have a heart murmur present and we are going to proceed with an echocardiogram placed.

Her workup during the initial appointment included an ACE level, which was normal. She also had a rather higher sed rate up to 30, but prior to that, per report, it was even higher, above 110. Her RVVT was normal, her rheumatoid factor was negative. Her ANA was 1:40, speckled pattern. The double-stranded DNA was negative. Her RNP and Smith were negative as well. RO and LA were negative and cardiolipin antibodies were negative as well. A urinalysis at the moment was completely normal. A CRP was 2.3 in the initial appointment, which was high. A CCP was negative. Her CBC had shown microcytosis and hypochromia with a hematocrit of 37.7. This improved later without any evidence of hypochromia, microcytosis or anemia with a hematocrit of 40.3.

The patient returns here today, as I mentioned, complaining of milder bouts of skin rash, which she calls erythema nodosum, which is accompanied by arthralgias, especially in the ankles. I am mentioning here that photosensitivity rash was mentioned in the past. She tells me that she had it twice back in Europe after skiing where her whole face was swollen. Her acne has been very stable after she was taken off prednisone and was started on colchicine 0.6 daily. Today we discussed about the effect of colchicine on a possible pregnancy.

MEDICATIONS: Prednisone was stopped. Vitamin D and calcium over the counter, we need to verify that. Colchicine 0.6 mg daily which we are going to stop, ranitidine 150 mg as needed, which she does not take frequently.

FINDINGS: On physical examination, she is very pleasant, alert, and oriented x 3 and not in any acute distress. There is some evidence of faint subcutaneous lesions in both shins bilaterally, but with mild tenderness, but no evidence of classic erythema nodosum. Stasis dermatitis changes in both lower extremities present. Mild livedo reticularis is present as well.

There is some periarticular ankle edema as well. Laboratory data from 04/23/07, show a normal complete metabolic profile with a creatinine of 0.7, a CBC with a white count of 7880, hematocrit of 40.3, and platelets of 228. Her microcytosis and hypochromia has resolved. Her serum electrophoresis does not show a monoclonal abnormality. Her vitamin D levels were 26, which suggests some mild insufficiency and she would probably benefit by vitamin D supplementation. This points again towards some ileum pathology. Her ANCA B and C were negative. Her PF3 and MPO were unremarkable. Her endomysial antibodies were negative. Her sed rate at this time were 19. The highest has been 30, but prior to her appointment here was even higher. Her ANA continues to be positive with a titer of 1:40, speckled pattern. Her double-stranded DNA is negative. Her serum immunofixation confirmed the absence of monoclonal abnormality. Her urine immunofixation was not performed. Her IgG, IgA, and IgM levels are normal. Her IgE levels are normal as well. A urinalysis was not performed this time. Her CRP is 0.4. Her tissue transglutaminase antibodies are negative. Her ASCA is normal and anti-OmpC was not tested. Gliadin antibodies IgA is 12, which is in the borderline to be considered equivocal, but these are nonspecific. I am reminding here that her homocystine levels have been 15.7, slightly higher, and that her methylmalonic acid was 385, which is obviously abnormal. Her B12 levels were 216, which is rather low possibly indicating a B12 deficiency. Her iron studies showed a ferritin of 15, a saturation of 9%, and an iron of 30. Her TIBC was 345 pointing towards an iron deficiency anemia. I am reminding you that her ACE levels in the past were normal and that she has a microcytosis. Her radiologic workup including a thoracic, abdominal, and pelvic CT did not show any suspicious adenopathy, but only small aortocaval and periaortic nodes, the largest being 8 mm in short axis, likely reactive. Her pelvic ultrasound showed normal uterus adnexa. Her bladder was normal as well. Subcentimeter inguinal nodes were found. There was no large lytic or sclerotic lesion noted. Her recent endoscopy was unremarkable, but the microscopy showed some eosinophil aggregation, which may be pointing towards allergy or an evolving Crohn disease. Her capsule endoscopy was limited secondary to rapid transit. There was only a tiny mucosal red spot in the proximal jejunum without active bleeding, 2 possible erosions were seen in the distal jejunum and proximal ileum. However, no significant inflammation or bleeding was seen and this could be small bowel crisis. Neither evidence of bleeding or inflammation were seen as well. Specifically, the terminal ileum appeared normal. Recent evaluation by a dermatologist did not verify the presence of erythema nodosum.

ASSESSMENT: This is a 25-year-old woman diagnosed with presumptive erythema nodosum in 2004. She has been treated with prednisone as in the beginning she had also a wrist and ankle discomfort and high inflammatory markers. Since I took over her care, I have not seen a clear-cut erythema nodosum being present. No evidence of synovitis was there. Her serologies apart from an ANA of 1:40 were negative. She has a livedo pattern, which has been worrisome. The issue here was a possibility of inflammatory bowel disease based on deficiency in vitamin B12 as indicated by high methylmalonic and homocystine levels and also iron deficiency. She also has low vitamin D levels, which point towards terminal ileum pathology as well and she had a history of decreased MCV. We never received the x-ray of her hands which she had and she never had a DEXA scan. Lymphoma has been ruled out and we believe that inflammatory bowel disease, after repeated colonoscopies and the capsule endoscopy, has been ruled out as well. Sarcoid is probably not the case since the patient did not have any lymphadenopathies and her ACE levels were normal. We are going check a PPD to rule out tuberculosis. We are going to order an RVVT and glycoprotein beta-1 levels in her workup to make sure that an antiphospholipid syndrome is not present given the livedo pattern. An anti-intrinsic factor will be added as well. Her primary care physician needs to workup the possible B12 and iron deficiency and also the vitamin D deficiency. In the meanwhile, we feel that the patient should stop taking the colchicine and if she has a flare of her disease then she should present to her dermatologist and have the skin biopsy performed in order to have a clear-cut answer of what is the nature of this skin rash. Regarding her heart murmur, we are going to proceed with an echocardiogram. A PPD should be placed as well. In her next appointment, we may fax a requisition for vitamin B replacement.

PROBLEMS/DIAGNOSES: 1. Recurrent erythema nodosum with ankle and wrist discomfort, ? arthritis.

2. Iron deficiencies, according to iron studies.

3. Borderline B12 with increased methylmalonic acid and homocystine.

4. On chronic steroids; vitamin D and calcium is needed; she needs a DEXA scan.

5. Typical ANCA, per records, were not verified here. ANCA and ASCA were negative and the OmpC was not ordered.

6. Acne.

7. Recurrent arthralgia not present. Rheumatoid factor, CCP negative, ANA 1:40 speckled.

8. Livedo reticularis, beta 2-glycoprotein was not checked, we are going to check it today. Needs vaccination for influenza and pneumonia.

9. Vitamin D deficiency. She needs replacement with ergocalciferol, but this may point towards ___________ pathology as this was not detected.

10. Recurrent ankle discomfort which necessitates ankle x-rays.

PLANS: We can proceed with part of her workup here in clinic, PPD, echocardiogram, ankle x-rays, and anti-intrinsic factor antibodies. We can start repleting her vitamin D with __________ weeks of ergocalciferol 50,000 weekly. We can add an RVVT and glycoprotein to her workup in order to rule out any antiphospholipid syndrome. She should be taking vitamin D and calcium after the completion of vitamin D replacement. She should be seen by her primary care physician, have the iron and B12 deficiency worked up. She should stop the colchicine and if the skin lesion recurs then she should be seen by her dermatologist. Based on the physical examination, we do not suspect that the patient has the presence of any other disease associated with erythema nodosum. We are going to add an amylase and lipase to evaluate her pancreatic function, RPR, HIV, __________ serologies. Given the evidence of possible malabsorption it may be significant to proceed with an upper endoscopy to rule out Whipple disease or celiac disease which can sometimes be associated with erythema nodosum. An anti-intrinsic factor would be added, as I mentioned. I doubt whether the patient has Behcet disease given the absence of oral or genital ulcers. She does not give a history of oral contraceptives or medications that could be related to erythema nodosum. She does not have any evidence of lupus __________ mycosis. Histoplasmosis coccidioidomycosis would be accompanied by other symptoms. Hodgkin disease has probably been ruled out with a CAT scan. However, we are going to add an LDH in future workup. I need to discuss with her primary care physician regarding the need for workup of her vitamin B12 deficiency and also with her gastroenterologist regarding the need for an upper endoscopy. The patient will return in 1 month.

Keywords: dermatology, iron deficiencies, anca, asca, ompc, ccp, itamin d deficiency, rvvt, serologies, vitamin d and calcium, erythema nodosum, iron deficiency, antibodies, deficiency, diseases, vitamin, erythema, biopsy, nodosum, inflammatory,

Sample Name: Excision - Actinic Neoplasm

DESCRIPTION: Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures

(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES:

1. Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.

2. Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.

3. A 1 cm x 1 cm seborrheic keratosis of the mid neck.

4. A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.

5. A 1 cm x 1 cm actinic keratosis of the right mid cheek.

POSTOPERATIVE DIAGNOSES:

1. Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.

2. Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.

3. A 1 cm x 1 cm seborrheic keratosis of the mid neck.

4. A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.

5. A 1 cm x 1 cm actinic keratosis of the right mid cheek.

TITLE OF PROCEDURES:

1. Excision of the left upper cheek actinic neoplasm defect measuring 1.5 cm x 1.8 cm with two-layer plastic closure.

2. Excision of the left lower cheek upper neck, 1 cm x 1.5 cm skin neoplasm with two-layer plastic closure.

3. Shave excision of the mid neck seborrheic keratosis that measured 1 cm x 1.5 cm.

4. Shave excision of the right superior pinna auricular rim, 1 cm x 1.5 cm verrucous keratotic neoplasm.

5. A 50% trichloroacetic acid treatment of the right mid cheek, 1 cm x 1 cm actinic neoplasm.

ANESTHESIA: Local. I used a total of 6 mL of 1% lidocaine with 1:100,000 epinephrine.

ESTIMATED BLOOD LOSS: Less than 30 mL.

COMPLICATIONS: None.

COUNTS: Sponge and needle counts were all correct.

I began excising the left upper cheek and left lower cheek neck lesions as listed above. These were excised with the #15 blade. The left upper cheek lesion measures 1 cm x 1.5 cm, defect after excision is 1.5 cm x 1.8 cm. A suture was placed at the 12 o'clock superior margin. Clinically, this appears to be either actinic keratosis or possible basal cell carcinoma. The healthy margin of healthy tissue around this lesion was removed. Wide underminings were performed and the lesion was closed in a two-layered fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.

The left upper neck lesion was also removed in the similar manner. This is dark and black, appears to be either an intradermal nevus or pigmented seborrheic keratosis. It was excised using a #15 blade down the subcutaneous tissue with the defect 1 cm x 1.5 cm. After wide underminings were performed, a two-layer plastic closure was performed with 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.

The lesion of the mid neck and the auricular rim were then shave excised for the upper dermal layer with the Ellman radiofrequency wave unit. These appeared to be clinically seborrheic keratotic neoplasms.

Finally proceeded with the right cheek lesion, which was treated with the 50% TCA. This was also an actinic keratosis. It is new in onset, just within the last week. Once a light frosting was obtained from the treatment site, bacitracin ointment was applied. Postop care instructions have been reviewed in detail. The patient is scheduled a recheck in one week for suture removal. We will make further recommendations at that time.

Keywords: dermatology, skin neoplasm, actinic neoplasm, seborrheic, keratosis, verrucous seborrheic keratosis, two-layer plastic closure, shave excision, superior pinna auricular rim, deep subcutaneous, plastic closures, seborrheic keratosis, neck, neoplasm, cheek, actinic,

Sample Name: Excision - Keratotic Neoplasm

DESCRIPTION: Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm.

(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES:

1. Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.

2. Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.

3. Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.

POSTOPERATIVE DIAGNOSES:

1. Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.

2. Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.

3. Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.

TITLE OF PROCEDURES:

1. Excision of the left temple keratotic neoplasm, final defect 1.8 x 1.5 cm with two layer plastic closure.

2. Excision of the left nasolabial fold defect 0.5 x 0.5 cm with single layer closure.

3. Excision of the right temple keratotic neoplasm, final defect measuring 1.5 x 1.5 cm with two layer plastic closure.

ANESTHESIA: Local using 3 mL of 1% lidocaine with 1:100,000 epinephrine.

ESTIMATED BLOOD LOSS: Less than 30 mL.

COMPLICATIONS: None.

PROCEDURE: The patient was evaluated preoperatively and noted to be in stable condition. Informed consent was obtained from the patient. All risks, benefits and alternatives regarding the surgery have been reviewed in detail with the patient. This includes risks of bleeding, infection, scarring, recurrence of lesion, need for further procedures, etc. Each of the areas was cleaned with a sterile alcohol swab. Planned excision site was marked with a marking pen. Local anesthetic was infiltrated. Sterile prep and drape were then performed.

We began first with excision of the left temple followed by the left nasolabial and right temple lesions. The left temple lesion is noted to be a dark black what appears to be a keratotic or possible seborrheic keratotic neoplasm. However, it is somewhat deeper than the standard seborrheic keratosis. The incision for removal of this lesion was placed within the relaxed skin tension line of the left temple region. Once this was removed, wide undermining was performed and the wound was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.

Excision of left cheek was a keratotic nevus. It was excised with a defect 0.5 x 0.5 cm. It was closed in a single layer fashion 5-0 nylon.

The lesion of the right temple also dark black keratotic neoplasm was excised with the incision placed within the relaxed skin tension. Once it was excised full-thickness, the defect measure 1.5 x 1.5 cm. Wide undermine was performed and it was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous, 5-0 nylon that was used to close skin. Sterile dressing was applied afterwards. The patient was discharged in stable condition. Postop care instructions reviewed in detail. She is scheduled with me in one week and we will make further recommendations at that time.

Keywords: dermatology, keratotic lesion, keratotic neoplasm, seborrheic keratotic neoplasm, seborrheic, keratotic, neoplasm, nasolabial, two layer plastic closure, nasolabial fold, excision,

Sample Name: Excision - Skin Neoplasm

DESCRIPTION: Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure. Shave excision of the right nasal ala skin neoplasm.

(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES:

1. Enlarging nevus of the left upper cheek.

2. Enlarging nevus 0.5 x 1 cm, left lower cheek.

3. Enlarging superficial nevus 0.5 x 1 cm, right nasal ala.

TITLE OF PROCEDURES:

1. Excision of left upper cheek skin neoplasm 0.5 x 1 cm with two layer closure.

2. Excision of the left lower cheek skin neoplasm 0.5 x 1 cm with a two layer plastic closure.

3. Shave excision of the right nasal ala 0.5 x 1 cm skin neoplasm.

ANESTHESIA: Local. I used a total of 5 mL of 1% lidocaine with 1:100,000 epinephrine.

ESTIMATED BLOOD LOSS: Less than 10 mL.

COMPLICATIONS: None.

PROCEDURE: The patient was evaluated preop and noted to be in stable condition. Chart and informed consent were all reviewed preop. All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient. Risks including but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures have been all reviewed. Each of these lesions appears to be benign nevi; however, they have been increasing in size. The lesions involving the left upper and lower cheek appear to be deep. These required standard excision with the smaller lesion of the right nasal ala being more superficial and amenable to a superficial shave excision. Each of these lesions was marked. The skin was cleaned with a sterile alcohol swab. Local anesthetic was infiltrated. Sterile prep and drape were then performed.

Began first excision of the left upper cheek skin lesion. This was excised with the 15-blade full thickness. Once it was removed in its entirety, undermining was performed, and the wound was closed with 5-0 myochromic for the deep subcutaneous, 5-0 nylon interrupted for the skin.

The lesion of the lower cheek was removed in a similar manner. Again, it was excised with a 15 blade with two layer plastic closure. Both these lesions appear to be fairly deep nevi.

The right nasal ala nevus was superficially shaved using the radiofrequency wave unit. Each of these lesions was sent as separate specimens. The patient was discharged from my office in stable condition. He had minimal blood loss. The patient tolerated the procedure very well. Postop care instructions were reviewed in detail. We have scheduled a recheck in one week and we will make further recommendations at that time.

Keywords: dermatology, enlarging nevus, nevus, skin neoplasm, nasal ala, cheek skin neoplasm, shave excision, superficial, lesions, neoplasm, excision, cheek,

Sample Name: Facial Rhytids

DESCRIPTION: Evaluation and recommendations regarding facial rhytids.

(Medical Transcription Sample Report)

HISTORY: This 57-year-old female who presented today for evaluation and recommendations regarding facial rhytids. In summary, the patient is a healthy 57-year-old female, nonsmoker with no history of skin disease, who has predominant fullness in the submandibular region and mid face region and prominent nasolabial folds.

RECOMMENDATIONS: I do believe a facelift procedure would be of maximum effect for the patient's areas of concern and a "quick lift" type procedure certainly would address these issues. I went over risks and benefits with the patient along with the preoperative and postoperative care, and risks include but are not limited to bleeding, infection, discharge, scar formation, need for further surgery, facial nerve injury, numbness, asymmetry of face, problems with hypertrophic scarring, problems with dissatisfaction with anticipated results, and she states she will contact us later in the summer to possibly make arrangements for a quick lift through Memorial Medical Center.

Keywords: dermatology, quick lift, hypertrophic scarring, facial rhytids, mid face region, nasolabial folds, lift,

Sample Name: Hyperesthesia

Description: Patient comes in for initial evaluation of a hyperesthesia on his right abdomen.

(Medical Transcription Sample Report)

SUBJECTIVE: This 49-year-old white male, established patient in dermatology, last seen in the office on 08/02/2002, comes in today for initial evaluation of a hyperesthesia on his right abdomen, then on his left abdomen, then on his left medial thigh. It cleared for awhile. This has been an intermittent problem. Now it is back again on his right lower abdomen. At first, it was thought that he may have early zoster. This started six weeks before the holidays and is still going on, more so in the past eight days on his abdomen and right hip area. He has had no treatment on this; there are no skin changes at all. The patient bathes everyday but tries to use little soap. The patient is married. He works as an airplane mechanic.

FAMILY, SOCIAL, AND ALLERGY HISTORY: The patient has sinus and CVA. He is a nonsmoker. No known drug allergies.

CURRENT MEDICATIONS: Lipitor, aspirin, folic acid.

PHYSICAL EXAMINATION: The patient is well developed, appears stated age. Overall health is good. He does have psoriasis with some psoriatic arthritis, and his skin looks normal today. On his trunk, he does have the hyperesthesia. As you touch him, he winces.

IMPRESSION: Hyperesthesia, question etiology.

TREATMENT:

1. Discussed condition and treatment with the patient.

2. Discontinue hot soapy water to these areas.

3. Increase moisturizing cream and lotion.

4. I referred him to Dr. ABC or Dr. XYZ for neurology evaluation. We did not see anything on skin today. Return p.r.n. flare.

Keywords: dermatology, abdomen, hyperesthesia, soapy water, moisturizing cream, initial evaluation,

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Description: Incision and drainage (I&D) of buttock abscess.

(Medical Transcription Sample Report)

PRINCIPAL DIAGNOSIS: Buttock abscess, ICD code 682.5.

PROCEDURE PERFORMED: Incision and drainage (I&D) of buttock abscess.

CPT CODE: 10061.

DESCRIPTION OF PROCEDURE: Under general anesthesia, skin was prepped and draped in usual fashion. Two incisions were made along the right buttock approximately 5 mm diameter. Purulent material was drained and irrigated with copious amounts of saline flush. A Penrose drain was placed. Penrose drain was ultimately sutured forming a circular drain. The patient's drain will be kept in place for a period of 1 week and to be taken as an outpatient basis. Anesthesia, general endotracheal anesthesia. Estimated blood loss approximately 5 mL. Intravenous fluids 100 mL. Tissue collected. Purulent material from buttock abscess sent for usual cultures and chemistries. Culture and sensitivity Gram stain. A single Penrose drain was placed and left in the patient. Dr. X attending surgeon was present throughout the entire procedure.

Keywords: dermatology, incision and drainage, purulent material, penrose drain, buttock abscess, i&d, drainage,

Sample Name: Mohs Micrographic Surgery - 1

Description: Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.

(Medical Transcription Sample Report)

PREOP DIAGNOSIS: Basal Cell CA.

POSTOP DIAGNOSIS: Basal Cell CA.

LOCATION: Mid parietal scalp.

PREOP SIZE: 1.5 x 2.9 cm

POSTOP SIZE: 2.7 x 2.9 cm

INDICATION: Poorly defined borders.

COMPLICATIONS: None.

HEMOSTASIS: Electrodessication.

PLANNED RECONSTRUCTION: Simple Linear Closure.

DESCRIPTION OF PROCEDURE: Prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.

The clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision. With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique. A map was prepared to correspond to the area of skin from which it was excised. The tissue was prepared for the cryostat and sectioned. Each section was coded, cut and stained for microscopic examination. The entire base and margins of the excised piece of tissue were examined by the surgeon. Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis.

No tumor was identified after the final stage of microscopically controlled surgery. The patient tolerated the procedure well without any complication. After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.

Keywords: dermatology, basal cell ca, basal cell, mohs technique, mohs, tumor-laden tissue, mohs fresh tissue technique, mohs micrographic surgery, micrographic surgery, parietal scalp, micrographic, basal, cell, ca, surgical, tumor, tissue, stage,

Sample Name: Mohs Micrographic Surgery - 2

DESCRIPTION: Mohs Micrographic Surgery for basal cell CA at medial right inferior helix.

(Medical Transcription Sample Report)

PREOP DIAGNOSIS: Basal Cell CA.

POSTOP DIAGNOSIS: Basal Cell CA.

LOCATION: Medial right inferior helix.

PREOP SIZE: 1.4 x 1 cm

POSTOP SIZE: 2.7 x 2 cm

INDICATION: Poorly defined borders.

COMPLICATIONS: None.

HEMOSTASIS: Electrodessication.

PLANNED RECONSTRUCTION: Wedge resection advancement flap.

DESCRIPTION OF PROCEDURE: Prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.

Keywords: dermatology, medial right inferior helix, wedge resection advancement flap, tumor-laden tissue, mohs fresh tissue technique, mohs technique, mohs micrographic surgery, basal cell ca, micrographic surgery, basal cell, micrographic, helix, basal, cell, ca, mohs, tissue, stage,

Dermatology

Sample Name: MRSA Infection - ER Visit

DESCRIPTION: Methicillin-resistant Staphylococcus aureus (MRSA) infection. A 14-day-old was seen by private doctor because of blister.

(Medical Transcription Sample Report)

HISTORY OF PRESENT ILLNESS: A 14-day-old was seen by private doctor because of blister. On Friday, she was noted to have a small blister near her umbilicus. They went to their doctor on Saturday, culture was drawn. It came back today, growing MRSA. She has been doing well. They put her on bacitracin ointment near the umbilicus. That has about healed up. However today, they noticed a small blister on her left temporal area. They called the private doctor. They direct called the Infectious Disease doctor here and was asked that they come into the hospital. Mom states she has been diagnosed with MRSA on her buttocks as well and is on some medications. The child has not had any fever. She has not been lethargic or irritable. She has been eating well up to 2 ounces every feed. Eating well and sleeping well. No other changes have been noted.

PAST MEDICAL HISTORY: She was born full term. No complications. Home with mom. No hospitalization, surgeries, allergies.

MEDICATIONS: As noted.

IMMUNIZATIONS: Up-to-date.

FAMILY HISTORY: Negative.

SOCIAL HISTORY: No ill contacts. No travel or changes in living condition.

REVIEW OF SYSTEMS: Ten systems were asked, all of them were negative except as noted above.

PHYSICAL EXAMINATION:

GENERAL: Awake, alert female, no acute distress at this time.

HEENT: Fontanelle soft and flat. PERRLA. EOMI. Conjunctivae are clear. TMS are clear. Nares are clear. Mucous membranes pinks and moist. Throat clear. No oral lesions.

NECK: Supple.

LUNGS: Clear.

HEART: Regular rate and rhythm. Normal S1, S2. No murmur.

ABDOMEN: Soft, nontender. Positive bowel sounds. No guarding, no rebound. No rashes seen.

EXTREMITIES: Capillary refill is brisk. Good distal pulses.

NEUROLOGIC: Cranial nerves II through XII intact. 5/5 strength in all extremities.

SKIN: Her umbilicus looks completely clear. There is no evidence of erythema. The area that the parents point where the blister was, appears to be well healed. There is no evidence of lesion noted, at this time. On her left temple area and just inside her hairline, there is a small vesicle. It is not a pustule. It is almost flat and it has minimal fluid underneath that. There is no surrounding erythema, tenderness. I have inspected the body, head to toe. No other areas of lesions seen.

EMERGENCY DEPARTMENT COURSE: I spoke with Infectious Disease, Dr. X. He states, we should treat for MRSA with Bactrim p.o. There has been no evidence of jaundice with this little girl. Hibiclens and Bactroban. I spoke with Dr. X's associate to call back after Dr. X recommended a Herpes culture be done, just for completeness and that was done. Blood culture was done here to make sure she did not have MRSA in her blood, which clinically, she does not appear to have. She was discharged in stable condition.

IMPRESSION: Methicillin-resistant Staphylococcus aureus infection.

PLAN: MRSA Instructions were given as above and antibiotics were prescribed. To follow up with their doctor.

Keywords: dermatology, blister, MRSA, methicillin resistant staphylococcus aureus, staphylococcus aureus, MRSA infection, infection, erythema, staphylococcus, aureus,

Sample Name: Poison Ivy - SOAP

DESCRIPTION: Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.

(Medical Transcription Sample Report)

SUBJECTIVE: He is a 24-year-old male who said that he had gotten into some poison ivy this weekend while he was fishing. He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it; he said that the last time he was here he got a steroid injection by Dr. Blackman; it looked like it was Depo-Medrol 80 mg. He said that it worked fairly well, although it seemed to still take awhile to get rid of it. He has been using over-the-counter Benadryl as well as cortisone cream on the areas of the rash and having a little bit of improvement, but this last weekend he must have gotten into some more poison ivy because he has got another outbreak along his chest, legs, arms and back.

OBJECTIVE:

Vitals: Temperature is 99.2. His weight is 207 pounds.

Skin: Examination reveals a raised, maculopapular rash in kind of a linear pattern over his arms, legs and chest area which are consistent with a poison ivy or a poison oak.

ASSESSMENT AND PLAN: Poison ivy. Plan would be Solu-Medrol 125 mg IM X 1. Continue over-the-counter Benadryl or Rx allergy medicine that he was given the last time he was here, which is a one-a-day allergy medicine; he can not exactly remember what it is, which would also be fine rather than the over-the-counter Benadryl if he would like to use that instead.

Keywords: dermatology, poison ivy, steroid injection, Depo-Medrol, maculopapular rash, poison oak, maculopapular, chest, ivy, poison,

Sample Name: Scalp Mole Skin Biopsy

DESCRIPTION: Skin biopsy, scalp mole. Darkened mole status post punch biopsy, scalp lesion. Rule out malignant melanoma with pulmonary metastasis.

(Medical Transcription Sample Report)

PROCEDURE: Skin biopsy, scalp mole.

INDICATION: A 66-year-old female with pulmonary pneumonia, effusion, rule out metastatic melanoma to lung.

PROCEDURE NOTE: The patient's scalp hair was removed with:

1. K-Y jelly.

2. Betadine prep locally.

3. A 1% lidocaine with epinephrine local instilled.

4. A 3 mm punch biopsy used to obtain biopsy specimen, which was sent to the lab. To control bleeding, two 4-0 P3 nylon sutures were applied, antibiotic ointment on the wound. Hemostasis was controlled. The patient tolerated the procedure.

IMPRESSION: Darkened mole status post punch biopsy, scalp lesion, rule out malignant melanoma with pulmonary metastasis.

PLAN: The patient will have sutures removed in 10 days.

Keywords: dermatology, k-y jelly, darkened mole, scalp mole, skin biopsy, punch biopsy, melanoma,

Sample Name: Skin Biopsy

DESCRIPTION: The skin biopsy was performed on the right ankle and right thigh. The patient was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient.

(Medical Transcription Sample Report)

The patient was consented for skin biopsy. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient. The skin biopsy was performed on the right ankle and right thigh.

PROCEDURE: The site was cleaned with antiseptic. A local anesthetic (2% lidocaine) was given at each site. A 3 mm punch biopsy was performed in the left calf and left thigh, above the knee. The site was then checked for bleeding. Once hemostasis was achieved, a local antibiotic was placed and the site was bandaged.

The patient was not on any anticoagulant medications. There were also no other medications which would affect the ability to conduct the skin biopsy. The patient was further instructed to keep the site completely dry for the next 24 hours, after which a new Band-Aid and antibiotic ointment should be applied to the area. They were further instructed to avoid getting the site dirty or infected. The patient completed the procedure without any complications and was discharged home.

The biopsy will be sent for analysis.

The patient will follow up with Dr. X within the next two weeks to review her results.

Keywords: dermatology, antiseptic, local anesthetic, hemostasis, punch biopsy, band-aid, skin biopsy,

Sample Name: Wasp Sting - SOAP

Description: Comes in complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm.

(Medical Transcription Sample Report)

SUBJECTIVE: He is a 29-year-old white male who is a patient of Dr. XYZ and he comes in today complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm. He says that he has been stung by wasps before and had similar reactions. He just said that he wanted to catch it early before he has too bad of a severe reaction like he has had in the past. He has had a lot of swelling, but no anaphylaxis-type reactions in the past; no shortness of breath or difficultly with his throat feeling like it is going to close up or anything like that in the past; no racing heart beat or anxiety feeling, just a lot of localized swelling where the sting occurs.

OBJECTIVE:

Vitals: His temperature is 98.4. Respiratory rate is 18. Weight is 250 pounds.

Extremities: Examination of his right hand and forearm reveals that he has an apparent sting just around his wrist region on his right hand on the medial side as well as significant swelling in his hand and his right forearm; extending up to the elbow. He says that it is really not painful or anything like that. It is really not all that red and no signs of infection at this time.

ASSESSMENT: Wasp sting to the right wrist area.

PLAN:

1. Solu-Medrol 125 mg IM X 1.

2. Over-the-counter Benadryl, ice and elevation of that extremity.

3. Follow up with Dr. XYZ if any further evaluation is needed.

Keywords: dermatology, yellow jacket wasp, wasp sting, swelling, Solu-Medrol, lot of swelling, stung, sting, wasp,

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