SUBJECTIVE: The patient is a (XX)-year-old woman who was seen for refill of her prescriptions six months ago. She returns stating that she has been having more problems with eczema in the past few months. She states she has been under a good deal of stress. She has been doing more cleaning than usual and is not wearing rubber gloves. The patient’s hands in particular are bothering her. Past medical history was negative for skin cancer. Her medications included Dermatop cream, Elidel cream to the face p.r.n. eczema, triamcinolone acetonide 0.1% ointment to the hands p.r.n. eczema, birth control pill, Ambien, Ativan, Adderall, Seroquel, Lamictal, Prozac, Tegretol, Zyrtec, Caladryl lotion to the hands, and Neosporin ointment. The patient has no known medication allergies.
OBJECTIVE: The patient is alert and oriented x3. There are erythematous crusted, slightly weepy plaques on the right fourth finger and right first finger and dorsal surface of the hand with less involvement on the palms. There are hypopigmented, slightly dry, scaly patches on the proximal arms and upper chest area, scattered eczematous 3 cm patches on the right cheek and lateral neck. The rest of complete skin examination is unremarkable.
ASSESSMENT: Atopic eczema.
PLAN:
1. We advised discontinuing the Caladryl and Neosporin to the hands. We think she has developed contact dermatitis. Discussed with her protecting her hands from repeated exposure to water with wearing gloves.
2. Clobetasol ointment to the hands b.i.d. for two weeks, then triamcinolone acetonide 0.1% ointment b.i.d. for two weeks.
3. She can continue with the Elidel 1% cream b.i.d. p.r.n. facial eczema.
4. We advised she discontinue tanning as we think it is worsening the dyschromia. She does have postinflammatory hypopigmentation from the eczema. She questions if Tri-Luma cream would be helpful with fading that is on her arms and legs. We told her it is highly unlikely it is going to have much of an impact, and we advised her regarding the cost of the medication, which will not be covered with insurance. The patient did not wish to pursue that. Further followup for the eczema scheduled for one month.
Sample #2
SUBJECTIVE: The patient is a (XX)-year-old gentleman who comes in today for a skin check. He has had two melanomas in the past; one was a Clark level IV 4.8 mm melanoma on his left arm. There were five mitoses per square millimeter with no ulceration. This was excised 1-1/2 years ago with a negative sentinel lymph node biopsy. Six months ago, he had another lesion distal to this, on his left wrist, that was removed and was shown to be a 1.4 mm thick melanoma level IV, less than one mitosis per square millimeter with ulceration absent. Of note, for the second melanoma, there was a question of epidermotropic metastasis; however, there was an in situ component to this suggesting a primary lesion but could not completely rule out epidermotropic metastasis on the pathology report. This was re-excised with a negative sentinel lymph node biopsy. The patient currently notes that he is doing well with no new or changing moles. He does point to a wart on his third finger of his left hand that he has had for quite some time. He also has one on the right finger web between the first and second digit as well.
OBJECTIVE: The patient is well appearing with normal respiratory effort. He is oriented with normal affect and mood.
ASSESSMENT AND PLAN:
1. Wart: On his third finger, on his left hand, he had a 3-4 mm hyperkeratotic papule, and this was frozen with liquid nitrogen with three brief freeze-thaw cycles. On the next visit, we will freeze it a bit harder if it appears to persist, and he did not get too much of an inflammatory response. Also, on his right finger web, he had a 3 mm papule that was frozen with liquid nitrogen as well.
2. History of melanoma x2: He had on his left forearm and left wrist two well-healed scar sites with no evidence of pigmentation or nodularity in or around the scar sites, as usual amelanotic. He will watch for pink lesions that are persistent, and he will continue self-skin checks.
3. Nevi: The patient had relatively few brown macules and papules scattered on torso and extremities but nothing concerning for malignancy.
We will see him back in Dermatology in one month to treat his warts, if it is still present, and in three months for his next skin check.
