SUBJECTIVE: The patient is a (XX)-year-old female who presents for check of moles. She has no particular lesions she is concerned about; although, she states her husband has told her that she has a lot of moles on her back. She does not think any of them are changing. She did have an atypical nevus removed from one of the toes on her right foot about 5 years ago. She did not require re-excision after the biopsy. She was told to have annual skin exams and she just has not followed through with it. Her other complaint is acne on her chest and back since she stopped birth control pills a couple of months ago. She would like to conceive.
PAST MEDICAL HISTORY: Negative for skin cancer.
FAMILY HISTORY: Negative for melanoma.
SOCIAL HISTORY: Moderate sun exposure. She does use sunscreen.
OBJECTIVE: Alert and oriented x3. Normal mood. Normal body habitus. Examined her face, neck, chest, breasts, abdomen, back, upper and lower extremities, hands and feet bilaterally. There were no lesions anywhere worrisome for cutaneous malignancy; however, she does have an above-average number of pigmented macular nevi. These range from 2-6 mm in diameter. The lesions appear similar to each other and are widely distributed on her chest, abdomen and back, few on her upper and lower extremities and face. On her upper back, there are scattered 2.5 mm inflammatory papules and pustules.
1. Mild truncal acne after stopping birth control pill.
2. Multiple nevi.
3. History of solitary atypical nevus.
1. Reviewed ABCDs of pigmented lesions, sun protection. Discussed self-exam. Advised she return for skin examination annually as the mole pattern she has does put her at a higher lifetime risk of development of melanoma.
2. As she is trying to conceive, she was given erythromycin solution to use b.i.d. for acne.
3. Followup is schedule in 1 year.
Dermatology SOAP Note Medical Transcription Sample Report #2
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old woman who comes in today for a skin check. She notes she has no personal or family history of skin cancer. She has had a couple of moles removed in the past because they were questionable, but she notes they were benign. She also has been using clindamycin, tretinoin 0.025% gel topical combination therapy for what she was told was milia and rosacea. She notes she used it, was not really helping and felt that it made her a little bit red and has discontinued it. She has a lot of questions about the lesions on her forehead, about rosacea, and about using facial moisturizers with sunscreen.
PHYSICAL EXAMINATION: The patient is well appearing. Normal respiratory effort. Oriented, normal affect and mood. Exam included the scalp, face, eyelids, conjunctivae, lips, neck, chest, abdomen, back, buttocks, right and left upper and lower extremity.
ASSESSMENT AND PLAN:
1. Milia. On her forehead and cheeks, she has multiple small 1.5 mm white papules consistent with benign milia and some yellowish papules on the forehead as well consistent with sebaceous hyperplasia. We discussed with her that we did not think that the clindamycin/tretinoin combination would really do much to get rid of milia and that the treatment of choice would be expressing the lesions and also we told her we believe they do dermabrasion at the cosmetic center for the smaller milia and she might want to check with someone there for cosmetic treatment if she wishes.
2. Sebaceous hyperplasia. She has several lobulated papules on her forehead. We discussed the medication that she is taking topically will not do anything to help these either. We discussed they are neither milia nor sebaceous hyperplasia or signs of rosacea, and in discussing further with her, it does not appear as if she has any acne-like pimples on her face. She does flush but it is more from emotional factors than it is from anything she ingests. We discussed we would not recommend a rosacea treatment based on these symptoms and signs. We did suggest, however, a sunscreen on a daily basis and we discussed a few recommendations for that. We also discussed that often using a heavy moisturizer can make one have milia more, but it does not seem as if she does that.
3. Seborrheic keratoses. She had multiple tan plaques on her skin, in particular her torso, with none concerning for malignancy.
4. Nevi. She had a few nevi on torso and extremities, again none concerning for malignancy. I will see her back in a year.
Dermatology SOAP Note Medical Transcription Sample Report #3
CHIEF COMPLAINT: Follow up granuloma annulare.
SUBJECTIVE: The patient is a (XX)-year-old male with history of granuloma annulare of the hands, who is here for followup. The patient was seen one month ago and had multiple lesions on the dorsum of both hands, treated with intralesional Kenalog, 3 mg/mL. Lesions have improved, but there are still slightly raised papules at the periphery on several of the lesions on both hands. The patient is diabetic but noticed no hypoglycemia from the Kenalog injections.
OBJECTIVE: Several scattered 0.9 to 3.6 cm annular plaques with hyperpigmentation, minimal resolving reddish pigmentation centrally with raised, pale pink, smooth borders on the dorsum of the hands extending onto the fingers. Several of the plaques have cleared, except for residual postinflammatory hyperpigmentation centrally but have no raised borders.
ASSESSMENT AND PLAN: Granuloma annulare on the dorsum of the hands, improving. Residual plaques were treated with intralesional Kenalog, 3 mg/mL, for a total of 2.2 mL injected. We will continue to monitor his sugars due to history of diabetes mellitus. The patient will return for followup in one month.
Dermatology SOAP Note Medical Transcription Sample Report #4
CHIEF COMPLAINT: History of actinic keratosis.
SUBJECTIVE: The patient is a (XX)-year-old woman with history of actinic keratosis here for yearly followup. She has had recurrence of a brown, slightly crusted growth in front of the right ear. She has noticed no other new or changing lesions. The patient has history of eczema and has intermittent flares with red scaly skin on the hands. She uses hydrocortisone 2.5% ointment, which helps but never completely resolves the rash when it is present. She also uses over-the-counter Lubriderm moisturizer.
OBJECTIVE: The patient is a well-developed, well-nourished female, alert and oriented. A complete skin examination including scalp, face, neck, chest, back, abdomen, all 4 extremities was performed and notable for:
1. A 5.5 x 4.5 mm tan verrucous stuck-on papule on the right preauricular area. Multiple scattered 4.5 to 12.5 mm hyperpigmented stuck-on plaques also around the trunk and extremities.
2. Diffuse fine white scale on the trunk and extremities with slightly increased scales of the legs. Also, ill-defined pale pink plaque with underlying fine white scale on the hands.
ASSESSMENT AND PLAN:
1. Seborrheic keratosis in the right preauricular area and scattered on the trunk and extremities. She was reassured these are benign and require no further treatment.
2. Diffuse xerosis and mild hand eczema. Skin care was reviewed. She will try switching to Lac-Hydrin 12% cream daily. Will also switch from hydrocortisone 2.5% ointment to triamcinolone 0.1% cream, may use it b.i.d. for two to three weeks as needed.
The patient will return for followup full skin examination in one year.
Dermatology SOAP Note Medical Transcription Sample Report #5
DIAGNOSIS: Impetiginized contact dermatitis with possible reaction related to application of vitamin E.
TREATMENT HISTORY: Triamcinolone cream applied twice a day for 2 weeks on the arms, back and legs to help with inflammation and itching. Prescription for Bactroban cream 2%, put directly at the impetiginized area for 7 days and oral antibiotic prescription for Keflex 500 mg twice a day for 10 days.
SUBJECTIVE: The patient is a well-appearing (XX)-year-old female last seen in Dermatology a few weeks ago. At the last visit, the patient reported to clinic regarding a new-onset rash about 4 nights prior. The rash began on the back and spread to her arms and legs predominately and her right knee. She had had recent knee replacement surgery for total knee replacement and was applying Gold Bond to the areas. She had also been applying vitamin E topically to the area where she had her knee replacement to facilitate healing.
OBJECTIVE: The patient has multiple excoriated papules with no primary lesions on the right upper arm. The upper back showed evidence of scant amount of excoriated papules and hemorrhagic crust, also no evident primary lesions. On the right leg, concentrated at the right knee, was a large, eczematous, red, fiery plaque with satellite pinpoint papules and honey-colored crust.
The patient has been faithfully applying the topical cream and taking the oral antibiotic. She experiences good relief with the treatment regimen; however, when she discontinued the use of the Bactroban, she started noticing worsening of the honey-crusted surface on her right knee.
ASSESSMENT: Marked improvement for impetiginized contact dermatitis, residual areas of inflammation and honey-colored crust remains on right knee.
PLAN: The patient was given renewal prescription for Bactroban. She is to apply this 3 times a day for the next 7 to 10 days on the right knee. She may continue using her triamcinolone only for the itchy areas for the next week or so, on her arms and back. She was also given dicloxacillin 500 mg twice a day for the next 10 days. Follow up in 1 week.
Dermatology SOAP Note Medical Transcription Sample Report #6
1. Basal cell carcinoma, right inner canthal area, status post Mohs surgery.
2. Biopsy-proven hypertrophic actinic keratoses on the left cheek.
3. History of skin cancer on the right cheek.
SUBJECTIVE: The patient is a well appearing (XX)-year-old female who returns to clinic regarding followup evaluation for her history of nonmelanoma skin cancer and also noting that there was a persistent irritating lesion on the right clavicle that has appeared since last visit that often catches on her sweaters, but is otherwise asymptomatic. However, upon further conversation, she notes it is tender sometimes upon palpation. Otherwise, she feels generally well today and has no additional skin concerns.
OBJECTIVE: The patient is a well-developed, well-nourished female, phototype II, in no apparent distress. She is alert and oriented x3. She ambulates independently. Today’s full dermatologic exam includes head, scalp, hair, face, neck, chest, abdomen, back, buttocks, upper extremities, hands, lower extremities and feet. Examination of genitalia declined. The right inner canthal area has well-healed scars, status post Mohs surgery, and no evidence of hyperpigmentation or overlying nodularity. On the face, multiple erythematous macules with gritty scale as well as some flat, verrucous brown papules. In the right medial anterior tibia is a 1 cm brown and slightly atrophic, well-defined patch with a superimposed hyperkeratotic papule. In the right clavicle is a 1 cm poorly defined erythematous patch with some flecks of darker pigmentation and scant scale.
1. No recurrence of history of basal cell carcinoma.
2. Actinic keratosis and seborrheic keratosis on the face.
3. Neoplasm of uncertain behavior, pigmented basal carcinoma versus inflamed seborrheic keratoses.
4. Atrophic marsupialized cyst on the right medial anterior tibia.
PLAN: Regarding the actinic keratosis, they were sprayed with liquid nitrogen on the face for a total of 5 sites. Photo precautions were encouraged. Skin self-examination was reviewed. Regarding the neoplasm of uncertain behavior, after consent was obtained and appropriate timeout, 0.5% lidocaine with epinephrine was injected into the site. A 3 mm punch biopsy utilizing #4 Prolene suture material was implemented. One simple interrupted suture was placed and appropriate topical wound care was given. The biopsy was sent for pathology. Regarding the atrophic marsupialized cyst, which was been existent for a long time, the patient was reassured. The patient will follow up in 2 to 3 weeks for suture removal and biopsy discussion.
Dermatology SOAP Note Medical Transcription Sample Report #7
CHIEF COMPLAINT: History of basal and squamous cell carcinoma.
SUBJECTIVE: The patient is a (XX)-year-old woman with history of basal and squamous cell carcinoma here for followup. She has history of squamous cell carcinoma, left breast, excised approximately one year ago and history of basal cell carcinoma on the back excised approximately nine years ago. The patient complains of significant itching of the scalp, particularly in the evenings, present for several months and present on a daily basis. She is not aware of any rash in the scalp. The patient denies proximal muscle weakness but does complain of myalgias in the proximal left arm and thighs bilaterally, which began around the same time the scalp pruritus began. The patient has noted a rough area on her left upper lip. Also has a raised bump of the left frontal scalp that she wants evaluated. The patient also recently noted a reddish rash on the chest. She is asymptomatic. She also has a slightly tender, irritated, raised lesion on the lower back that she wants evaluated.
OBJECTIVE: The patient is a well-developed, well-nourished female, alert and oriented. Complete skin examination including scalp, face, neck, chest, back, abdomen, and all four extremities were notable for:
1. Well-healed scar on the left chest. No evidence of recurrent skin cancer.
2. No erythema or scale on the scalp.
3. The patient has 5/5 strength of the upper arms and thighs.
4. A 3 x 3 mm pink, thin, rough plaque on the left upper cutaneous lip.
5. Pink, rough, slightly hyperkeratotic plaque on the lower back.
6. Mid chest area with coalescing reddish brown, thin plaques with no overlying scale. KOH positive for multiple hyphae and spores.
7. Approximately 8 x 7 mm hyperpigmented, stuck-on plaque on the left frontal scalp. Also, on the face, trunk, and extremities scattered 4 to 10 mm hyperpigmented stuck-on plaques.
ASSESSMENT AND PLAN:
1. History of squamous cell and basal cell carcinoma as noted above. No evidence of recurrence.
2. Pruritus of the scalp. The patient has no evidence of seborrheic or allergic contact dermatitis. No history of diabetes noticed. Of note, the patient complains of myalgias of the proximal extremities and cannot entirely rule out dermatomyositis, although has none of the other stigmata of it, including heliotrope periorbitally or shawl-like rash on the upper trunk. The patient will have CPK, aldolase, ALT, AST, ANA, glucose and sed rates checked today. If these are within normal limits and she continues to complain of myalgias, she should discuss this further with her primary care physician.
3. Actinic keratosis on her left upper cutaneous lip. The lesion was treated with liquid nitrogen for 7 seconds.
4. Inflamed seborrheic keratosis versus actinic keratosis versus squamous cell carcinoma of the lower back. Diagnostic and therapeutic shave biopsy was performed. Photographs were taken of the site. Written consent was obtained for the biopsy. There was a time-out for person and procedure verification. The area was anesthetized with 0.8 mL of 0.5% lidocaine with epinephrine. Hemostasis was achieved with Drysol. Bacitracin and Band-Aid applied and wound care explained.
5. Tinea versicolor on the chest. Diagnosis and pathophysiology were discussed. The patient states that another physician had given her Lotrisone, which she has been using for the last several days and was instructed to discontinue this due to risk of skin atrophy from the topical corticosteroid, which is not needed. Instead, she will treat with Nizoral cream twice a day for up to several weeks until this resolves.
6. Seborrheic keratoses on the scalp, face, trunk and extremities. Reassured these are benign and require no further treatment.
Dermatology SOAP Note Medical Transcription Sample Report #8
SUBJECTIVE: The patient is now four years post excision of the basal cell carcinoma of the left forehead and roughly two years post excision of another squamous cell carcinoma of the left ear lobe. The patient has noticed some rough crusted lesions on his forehead and scalp area. Other than that, he has noted no other new unusual skin lesions. He has no known allergies to medications. The only medications he takes are Lipitor and atenolol. Other than that, review of systems is negative. Family history is negative.
OBJECTIVE: On examination, he is a pleasant, well-developed, well-nourished man who appears to be in no acute distress. He is oriented to person, time, and place. His mood, affect, and grooming appear normal to me. Full surface skin examination was carried out. There were well-healed scars on the left ear lobe and left forehead without clinical evidence of recurrence. On his scalp, the patient had rough crusted lesions along the hairline and one posteriorly and one on the left cheek. No nodes were palpable over the neck, supraclavicular, axillary or groin areas. He did have some scattered keratosis on the trunk anteriorly and posteriorly. Some lentiginous lesions on the upper back but no other active or unusual lesions were noted in all areas checked.
1. Basal cell carcinoma of the forehead, four years post excision.
2. Squamous cell carcinoma, left ear lobe, two years excision. No evidence of recurrence on either side.
3. Actinic keratosis.
4. Seborrheic keratosis.
PLAN: After discussion with the patient of the possible side effects of liquid nitrogen cryosurgery and then with his verbal consent, five actinic keratoses were treated on the scalp, the left cheek and along the hairlines bilaterally, anteriorly. We discussed some precautions and the need for following. Follow up in one year.
Dermatology SOAP Note Medical Transcription Sample Report #9
1. Status post excision of small basal cell carcinoma, left upper neck.
2. Actinic damage, skin.
SUBJECTIVE: The patient is a well-appearing (XX)-year-old female last seen in Dermatology a few months ago. She returns to the clinic regarding continuing followup and evaluation subsequent to her history of nonmelanoma skin cancer. According to the patient, the site is well healed. She denies any pain, itch, spontaneous bleeding or emergence of new lesions in the area. She feels generally well today and has no new skin concerns.
OBJECTIVE: The patient is a well-developed, well-nourished female, phototype II to III. She is in no apparent distress. She is alert and oriented x3. Today’s full dermatologic exam included head, scalp, ears, face, neck, chest, abdomen, back, buttocks, upper extremities, hands, lower extremities and feet. Examination of the genitalia was declined. Located on the left upper neck was a well-healed linear scar, status post excision with no evidence of hyperpigmentation or overlying nodularity or evidence of skin lesions. There were multiple brown and skin-colored verrucous papules on the torso predominantly. Also, diffuse actinic damage manifested by ephelides and coalescing lentigines.
ASSESSMENT: No lesions suspicious for cutaneous malignancy. Today’s exam was clinically benign.
PLAN: The ABCDs of melanoma and photo precautions were reviewed. Skin self-examination was encouraged. Follow up in 6 months.