Dermatology Case Study

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ADMISSION DIAGNOSES

1. Left lower leg cellulitis.

2. Left lower leg ulceration.

3. Diabetes mellitus.

4. Urinary frequency.  Rule out urinary tract infection.

5. Hypertrophy of gums.

6. Right popliteal mass.

7. Possible psoriasis.

DISCHARGE DIAGNOSES

1. Left lower leg cellulitis.

2. Left lower leg ulceration.

3. Diabetes mellitus.

4. Urinary frequency.  Rule out urinary tract infection.

5. Hypertrophy of gums.

6. Right popliteal mass.

7. Possible psoriasis.

ADMIT INFORMATION

Full history and physical have been dictated.  Briefly, this is a 48-year-old white female with obesity and diabetes who has had a smoldering left lower extremity cellulitis for the past 2 to
3 months.  It is possibly related to her pruritus and psoriasis.  She has been treated in the past with Coumadin and IV antibiotics.  On the day of admission she presented to my office with worsening of the cellulitis and a new 2-cm ulceration and was admitted for IV antibiotics and further evaluation.

ALLERGIES

ALLERGY TO PENICILLIN AND SULFA AND POSSIBLY TO COUMADIN.

Medications on admission were Procardia, Mellaril, Aldactone, Glucotrol, and hydrochlorothiazide.  The extremities revealed bilateral edema 1 to 2+ to the knees, with erythema and diffuse excoriations with erythema from the ankle to the midshin area on the left lower extremity.  She had a 2 x 2-cm superficial ulcer on the lateral aspect of the ankle.  Of note on the right popliteal fossa, she had a mobile, firm mass, 2 x 2 cm.

Laboratory on admission revealed urine with 80 to 150 wbc’s, 3 to 6 rbc’s, 10 to 15 epithelials, but only a few bacteria.  Sodium was 138.  Electrolytes were normal.  BUN and creatinine were normal.  The creatinine was 1.4, which is probably acceptable for this obese woman.  PT was slightly elevated at 15.6.  PTT was normal.  Subsequent chemistry panel was essentially normal.  CBC revealed a white blood cell count of 6, hemoglobin of 12, hematocrit of 35, with 345,000 platelets and a normal smear.

HOSPITAL COURSE BY PROBLEMS

1. Cellulitis and ulceration as well as chronic skin problems.  The patient was seen in consultation by a dermatologist who confirmed my diagnosis of cellulitis.  She was placed on IV Kefzol for 48 hours with marked improvement in her cellulitis.  Her skin condition was consistent with lichen simplex chronicus, and she was begun on Topicort cream b.i.d.  Her Coumadin was not continued as she had no venogram or Doppler evidence of deep venous thrombosis in the past.  As well, she seems to feel that the Coumadin made her rash worse.

2. Gum hypertrophy.  I felt that this was most likely periodontal disease but checked a CBC to make sure she had no evidence of leukemia with leukemic infiltrates.  The CBC was normal, and she will see her private dentist on discharge.

3. History of urinary tract infection.  The admission UA was abnormal.  I have obtained a catheterized specimen for urinary culture.  As she will be on Keflex antibiotics for the cellulitis on discharge, I will give no other antibiotics until the results of the urine culture are back.

DISCHARGE MEDICATIONS

Glyburide 2.5 mg q.d., Keflex 500 mg p.o. q.i.d., Lasix 20 mg q.d., Mellaril 50 mg q.h.s., Topicort cream to affected areas b.i.d., and normal saline dressing changes for wound care.

FOOTNOTE

Line 16 (Page 1).  Although the dictator said “as above” for the Discharge Diagnoses, it is preferable to type the diagnosis in full.

Lines 28, 29 (Page 1).  Alternative:  2-3 months.

Line 26 (Page 1).  Allergies were classified under a separate heading for clarity.

Lines 46, 47 (Page 1).  Alternative:  80-150 wbc’s, 3-6 rbc’s, 10-15 epithelials.  The slang term epis was translated as epithelials.  Alternative:  epithelial cells.

Line 1 (Page 2).  Chem panel was expanded to chemistry panel.

Line 8 (Page 2).  Alternative:  I.V.

Line 22 (Page 2).  The slang term cath was translated as catheterized.

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.

Dermatology Case Study

To Whom It May Concern,

I am sending you this registered letter so that I have legally discharged to you my responsibility in regard to the skin cancer which we discussed on your last visit.  My office manager advises me that you are currently trying to arrange some sort of insurance coverage.

It is my obligation to advise you clearly that this tumor is a cancer, that it should be treated promptly, in my opinion within the next 4 to 6 weeks.  I have already discussed with you at length the treatment which I feel is appropriate, that is, excision under frozen control and closure with an advancement flap.  Delay in having this done can result in a less satisfactory cosmetic result, greater expense, and if it is delayed long enough, could result in a tumor which becomes unresectable and could lead to severe disfigurement, and in very rare cases these tumors have, when uncontrolled, resulted in a patient’s death.

I therefore have an obligation to urge you to seek prompt treatment in regard to this lesion.

Very truly yours,

Name.

FOOTNOTE

Line 13.  The physician who dictated this letter originally addressed it To Whom It May Concern because it was to be sent to an insurance company by the patient.  Out of context, it appears to be an instruction error.  Therefore, it would be acceptable for the transcriptionist to supply a different salutation.

Line 23.  The dictated word and was deleted to shorten the sentence.

Line 23.  Alternative:  4-6 weeks.

Dermatology case Study

EMERGENCY ROOM REPORT

This patient presents on the above date with a laceration to his left hand at the interdigital web space between the first and second digits on the left hand.  It was infiltrated with
1% Xylocaine and cleansed with Betadine on a cotton tip, explored for foreign bodies, none of which were found.  Sensory and vascular status and motor status were within normal limits.  Surgical repair was performed using 4-0 Ethilon x4.  Excellent cosmetic and functional results are anticipated.

IMPRESSION

A 1-cm laceration to the left hand with surgical repair.

FOOTNOTE

Line 9.  Digit was changed to digits for plural agreement.

Line 12.  Was was changed to were for subject-verb agreement (status ... and status ... were).

Line 17.  The article A was added to avoid beginning the sentence with a numeral.

Dermatology Case Study 11

INITIAL OFFICE EVALUATION

Developed a right breast carcinoma approximately 3 years ago, which was treated by a surgical resection.  She subsequently developed metastases about 1-1/2 years ago in the right hip and right shoulder.  These have been treated with a combination of radiation plus tamoxifen, and she has done really quite well with a regression of the metastases, stabilization, and no apparent significant progression.  Approximately a year and a half ago, immediately concomitant with her radiation therapy, she developed a persistent and intensely pruritic dermatitis at the radiation port on the midchest.  This dermatitis has remained stable without spread over the past year and a half.  Approximately
3 weeks ago she developed a similar but intensely pruritic weeping lesion on the dorsal aspect of the proximal phalanx of the left index finger.  This dermatitis rapidly spread to involve the left elbow.

Examination reveals that she has had a right mastectomy.  The scar is well healed, and there is no evidence of local or deep recurrence.  Examination of the midchest reveals a localized, lichenified, excoriated, eczematous eruption consistent with a lichen simplex chronicus.  On the dorsum of the left second digit, proximal phalanx, there is an area of moist, weeping, eczematous dermatitis.  Similar involvement is noted over the left elbow.

It is my impression that the lesions on the chest represent a lichen simplex chronicus, i.e., a chronic localized eczematous dermatitis, probably induced by the trauma of the radiation.  The lesions present there do not resemble those usually seen in cutaneous metastases of the breast carcinoma.  In addition, one would have expected significant progression over this period of time.  The lesions on her left second digit and elbow are consistent with a wet form of nummular eczema.  This type of eczema is common in elderly patients because of their dry skin and represents a combination of an eczematous response to a
low-grade superficial secondary infection.

I have advised her that I do not feel this eruption is related to her previous breast carcinoma, and I definitely do not feel that there is any relationship to her tamoxifen therapy.  I have started her today on oral erythromycin 250 mg t.i.d. and triamcinolone cream 0.1% with small amounts of menthol and phenol added, to be applied t.i.d. to all affected areas and in addition as needed to control itch.  I have asked her to recheck with me in approximately 2 weeks to note progress.  Provided the eruptions regress, then no further investigation is indicated.  Should they fail to regress promptly, I would consider a diagnostic punch biopsy.

FOOTNOTE

Line 9 (Page 1).  Metastasis was changed to metastases for plural agreement.

Lines 16, 25 (Page 1).  Alternative:  Mid chest.

Lines 49, 50 (Page 1).  The redundant p.r.n. was deleted.