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.
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. She is aware of risks include
but not limited to bleeding, infection, scarring, recurrence of the lesion,
need for further procedures, etc. The areas of concern were marked with the
marking pen. Local anesthetic was infiltrated. Sterile prep and drape were then
performed.
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.
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, 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,