A 34-year-old lady who comes to clinic today with longstanding history of hypothyroidism, for which she has taken Cytomel in the past. Comes in today for a refill of medication and further evaluation.
Examination shows her to be in no acute distress. Blood pressure 120/88. HEENT normal. Chest is clear. Cardiac examination reveals regular rate and rhythm without murmur.
ASSESSMENT
A 34-year-old lady with longstanding hypothyroidism. I would prefer to switch her to Synthroid 0.1 mg as I think the packaging is more uniform in this product. Then test thyroid-stimulating hormone in 1 month.
FOOTNOTE
Line 7. The article A was added to avoid beginning the sentence with a numeral.
Line 13. The blood pressure value 120 by 88 is written 120/88.
Line 18. A zero was inserted before the decimal point for clarity.
Lines 19, 20. TSH is expanded in the assessment for clarity.
4. Urinary frequency. Rule out urinary tract infection.
5. Hypertrophy of gums.
6. Right popliteal mass.
7. Possible psoriasis.
DISCHARGEDIAGNOSES
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.
The patient is an elderly, pleasant female who is quite cooperative.She was admitted to the hospital because of cellulitis of the right lower extremity.There has been blistering of the area on the dorsum of the foot as well as higher up towards the ankle.She has redness extending all the way up to the mid-pretibial area.There is no history of lymphadenopathy, and judging from the chart, she has been afebrile.She was started, after finding out that her white count was abnormal, on Cefobid and tobramycin and infectious disease consultation sought.
PHYSICAL EXAMINATION
Exam today shows a temperature of 37 degrees Centigrade, a blood pressure of 130/70, a respiratory rate of 20, and pulse rate of 80. General appearance:An elderly female in no acute distress.
Head and ENT:Grossly negative. Neck:Supple. Lungs:Clear and resonant. Heart:Grade 1 systolic murmur; otherwise negative.
Abdomen:Scars of surgery.The abdomen is not obese but protruding.She has some left lower quadrant discomfort that is mild. Vaginal and rectal:Not done. Lymph nodes:No enlargement. Exam of the extremities reveals blistering cellulitis over the dorsum of the foot with swelling and extension of the abnormal coloration to the mid-pretibial area.The foot appears warmer than the other.
After sterile preparation the 2 blisters were aspirated, 0.2 cc of fluid was taken out, and this was sent for Gram stain and culture.
IMPRESSION
Probable streptococcus cellulitis.
DISCUSSION
The patient has had a Gram stain done yesterday, and it does show gram-positive cocci.This may well be staph, but I think we should give her penicillin till the culture reports are out.The blistering is typical of strep.I would go ahead and give her 2 million q.6h. of the penicillin and modify therapy according to culture report.
I thank you for allowing me to participate in the care of this pleasant, elderly female and will reassess p.r.n.
FOOTNOTE
Line 42.The brief form strep was expanded to streptococcus in the Impression.
Returns today.Zoster still quite active.No new blisters forming.Still has many active vesicles present.
Because there is still active dermatitis, it is too early to start Zostrix.I will maintain her on Darvocet-N 100 (she has a refill), hydroxyzine 50 mg one-half hour prior to bedtime for sleep.We will initiate a gradual prednisone taper; 40 mg q.a.m. for the next 5 days, 20 mg q.a.m. for 5 days, 10 mg q.a.m. for 5 days.Patient was advised to carefully check her sugar levels since they may begin to drop as the prednisone dose is weaned.She is currently on insulin because of aggravation of her diabetes.She is to recheck with me in 2 weeks.At that time, provided she is minimally symptomatic, I will plan to taper her fairly rapidly off of the remaining prednisone and initiate topical Zostrix therapy.
CHART NOTE
Returns today.Oral cavity, especially the cheeks and labial mucosa, are improved.Soles have improved.Palms have improved but are still painful because of fissures.Main problem is the lower lip, which is still denuded and is showing some granulation tissue where it had been de-epithelialized by the disease.He is to remain on Accutane 50 mg per day, prescription given.He has no history of hypertension, ulcers, diabetes, glaucoma, or tuberculosis.I will therefore place him on a short burst of prednisone to try and get the disease under better control.He is to take 40 mg q.a.m. for 3 days, 20 mg x3 days, 10 mg x3 days, 5 mg x3 days, 2.5 mg x4 days, and then off.He is to continue the use of Lidex ointment to the lower lip, Lidex ointment covered with urea cream to the palmar and plantar lesions.He is to recheck in 3 weeks for followup.Lab work on the Accutane will be obtained at that time.
CHART NOTE
She is 11 years of age and is here today with her parents regarding 2 problems.
1. A thick scar on the left upper lip adjacent to the nasolabial fold.This was from excision of a mole.This was done a year ago.The scars thickened almost immediately.
On examination today there is a hypertrophic spread scar on the left upper lip following the contour of the nasolabial fold.It measures approximately 1.2 x 0.5 cm.It is at the present time relatively quiescent, uninflamed, and nonsymptomatic.
DISPOSITION
I have recommended no active therapy unless the scar begins to enlarge.Provided it is stable, I advised them to watch it for a couple of years before considering any sort of reparative procedure.If it is acceptable at that time, I would leave it alone; otherwise, consult with me again considering a possible repair.I advised them, however, that even under the best circumstances, any attempt at revision could result in more scar formation.
2. On her right mid lower back she has a 5-mm, medium-brown, clinically benign, sharply marginated, evenly colored nevus, dermal in character, with normal skin lines.This lesion has been subject to repeated trauma.The parents wish it gone.
I have explained to them both at length the difference between shave and excisional removal.The mother was already familiar with it.I have warned them about them about the possibility of thick scar formation, which they accept.After a full explanation, at their request the lesion was shave excised and submitted for microscopic examination.Because of tendency towards thick scar formation, I have asked them to recheck in 1 month so that I can look at it, immediately if any difficulties are encountered.
CHART NOTE
Returns today.Patch tests to cosmetics are negative.Eruption is clear.
Patient is to recheck if there are any further difficulties.She was advised that she may resume the use of her cosmetics.This appears to be simply a localized atopic eczema.
CHART NOTE
Returns today.She was doing well, then had a sudden exacerbation of her dermatitis 3 days ago.
Examination today reveals now an acute eczematous dermatitis which for the first time shows a fairly definite pattern over her buttock area, low midback, and shoulders.I have again gone through her history for possible contactants.We have already gone through her laundry products; these have been either eliminated or changed.History reveals that the flaring occurred about a day after she restarted her aerobic classes.For these classes she wears a stretch spandex suit.In addition, I examined her underwear today; they are of a heavy stretch type, they contain 12% spandex, and portions of her brassiere panels contain 16% spandex.Patients are often allergic to the rubber chemicals in these products.It would appear that she probably has a rubber chemical sensitivity, specifically to the product spandex.
I have recommended that she eliminate temporarily all spandex-containing clothes, anything that is elastic or stretchy, and in particular she is to also examine her bathing suit.Temporarily switch to cotton underwear with as little elastic product as possible, do not bleach them, and be sure that they do not contain brand-name spandex.Given a new supply for triamcinolone cream, 2 ounces plus 3 refills, 0.1%, use t.i.d. and p.r.n. itch till clear.As soon as her dermatitis has settled down, I plan to patch test her to cuttings from the actual products plus the rubber chemicals.Fortunately, the history and pattern of dermatitis were more specific today.
CHART NOTE
A 31-year-old woman who has had a chronic problem with tinea pedis and onychomycosis.Was treated with oral griseofulvin.The griseofulvin cleared her feet, but she developed a generalized rash and allergic reaction to the drug before she was able to achieve clearing of her toenails.Approximately a year and a half ago she saw Dr. (blank) and was treated with multiple topical agents including miconazole, Nizoral, and Loprox, with no significant result.It is noted, however, that the patient only used the Loprox for about 3 months, and no debridement was done.
On examination today she presents with an onychomycosis involving about 60% of the right great toenail.The right fourth and fifth nails and left second and fifth nails are involved to the base.The other nails, toe webs, and soles are clear.The findings are consistent with a dermatophyte infection.
IMPRESSION
1. Tinea pedis by history, currently clear.
2. Onychomycosis involving 5 of 10 toenails.
DISPOSITION
I have explained to her the other alternative medication, ketoconazole, and I have warned her about its potential serious liver toxicity, advising her that there have been some rare but significant reactions with jaundice, prolonged recovery times, and 1 reported death.I advised her that these reactions are quite rare, about 1 in 15,000 patients, and if she desires an alternative agent to try and treat the nails, this would be at the present time our only available medication.She indicated that her nails are painful and interfering with walking and that she does desire, if possible, to try and clear them.Therefore, I have placed her on Nizoral 200 mg per day, 45 dispensed plus no refill.A chemistry panel is to be done prior to onset of therapy, 3 weeks from now, and she is to return for followup in 6 weeks.
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.
