DATE OF VISIT: MM/DD/YYYY
CHIEF COMPLAINT: Cracked feet.
HISTORY OF PRESENT ILLNESS: This patient was seen by Dr. John Doe for psoriasis in August of last year. She says that her psoriasis has been fairly well controlled with Dovonex and clobetasol topical medications. The patient complains of cracking and bleeding around her heels for the last couple of years. She says that it was never a problem when she was younger, and she has not been treating it with anything. She also complains of fungus in her toenails. She is very bothered by this, and she would like to discuss treatment options. She complains of a red spot on her right chin that has been present for one year. Initially, she thought it was a pimple, but since it has not gone away, she is concerned it could be skin cancer.
MEDICATIONS: Hydrochlorothiazide, fluoxetine, fish oil, Crestor, Centrum Silver, clonazepam, Prosed, and ibuprofen.
ALLERGIES: Penicillin.
PHYSICAL EXAMINATION: This is a pleasant (XX)-year-old Asian woman, who is awake, alert and oriented x3, in no acute distress with normal mood and affect. Skin examination included face, scalp, hair, neck, chest, abdomen, back, arms, legs, hands, and feet bilaterally and buttocks. On the right chin, there is a 3 mm pink, scaly plaque. On her toenails bilaterally, she has toenail polish, so it is difficult to assess whether there is nail discoloration. She does have some nail thickening and mild subungual debris. Around the heels of her feet bilaterally, she has healing fissures. She does have hyperkeratosis and dry skin.
IMPRESSION AND PLAN:
1. Actinic keratosis x1 on the right chin. After verbal consent was obtained, this was treated with cryotherapy. Wound care was discussed.
2. Onychomycosis. Fungal nail culture was sent. We will call her with the results.
3. Xerosis. We prescribed 50% urea cream b.i.d. The patient was reassured.
FOLLOWUP: In six months to reassess the onychomycosis and further discuss treatment options, sooner p.r.n.
