Dermatology Case Study

CHART NOTE

Patient is 36 years old and has a 16-year history of patchy psoriasis.  On examination today he has a localized area of psoriasis on the right frontal scalp and involvement of both elbows but is otherwise clear.  The impression today is stable plaque psoriasis.

For the scalp he was started on Neutrogena T/Gel shampoo to be used on a daily basis, with Diprolene lotion to be applied b.i.d. until clear; 2 ounces were dispensed plus 3 refills.  For the elbow lesions he was given a refill of the Diprolene ointment to be applied b.i.d. when active, and the left elbow was injected and one-third of the right elbow was injected using a total of
4 cc of 2.5 mg/cc of Kenalog diluted in solution.  The patient is to recheck in 1 month so that the injections can be completed.

FOOTNOTE
Line 19.  Two and a half was changed to 2.5 because metric numbers use decimals, not fractions.

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