Dermatology Draft Current 1

SUBJECTIVE:
[text default="CC:" size=100]
HPI:
Pt was seen and examined:
[text size=5] year old [comment memo="Race: "] [text size=10 ] [select value="male|female"] presents with a previous history of: [checkbox name="variable_1" value="No Relevant PMI |Melanoma |SCC |BCC |Psoriasis |Thyroid disorder |DM |Atopy |STI |HIV/Immunocompromised"][text size=50]
[checkbox name="variable_2" value="They were last seen in dermatology:"][text size=10]
[checkbox name="variable_3" value="Pt complains of a skin lesion |Pt complains of a skin rash"][checkbox name="variable_4" value="Location: "][text size=50]
[checkbox name="variable_5" value="Started: "] [text size=50]
[checkbox name="variable_6" value="Description Free Text: "][textarea name="variable_7" default=""][checkbox name="variable_8" value=" Asymptomatic |Pruritic |Painful |Spreading |Non-Spreading"][checkbox name="variable_41" value="Increased in Size |Decreased in Size |Has Not Changed is Size or Shape"][text size=10]
Provocative Factors:[checkbox name="variable_9" value=" None |Heat |Cold |Sun |Exercise |Medications |Food"][text size=10]
Relieving Factors:[checkbox name="variable_10" value=" None |Heat |Cold"][text size=10]
Pertinent Past Medical History:
[textarea name="variable_38" default=""]
Medications:
[textarea name="variable_11" default="Reviewed Medications; No medications are relevant to current skin condition."]
[checkbox name="variable_12" value="Family History: "][checkbox name="variable_13" value="Psoriasis |Atopy |Skin cancer "][text size=50]
[link memo="Go to Social History" mark="Social History"]
[checkbox name="variable_14" value="Skin ROS:"][text size=50][checkbox name="Variable_15" value="REVIEW OF SYSTEMS Patient Denies the Following: "][checkbox name="variable_16" value="General: Fever/Chills, Unexplained Weight Loss/Gain, Fatigue, Night Sweats |HEENT: Changes in vision, hearing, balance, bowel/bladder habits; headaches, congestion, runny nose, ear pain, sinus pain, sinus discharge |Cardiovascular: chest pain, claudication, dyspnea, dyspnea on exertion, palpitations, PND, orthopnea, diaphoresis |Respiratory: cough, congestion, runny nose, hemoptysis, sore muscles, wheezing, dyspnea, dyspnea on exertion |Abdomen: heartburn, hematemesis, hematuria, hematochezia, melena, mucus in stool, constipation, anorexia, nausea, vomiting, diarrhea |Musculoskeletal: numbness, tingling, erythema, increased warmth of joint or site, swelling of joint or site, shooting pain, saddle anesthesia, weakness, joint pain |Neurology: Denies headaches, fainting, seizures, sudden weakness on half of face or body, parasthesias, difficulty walking, confusion, tremors |Endocrinology: thyroid issues, polyphagia, polyuria, polydipsia |Skin: ulcers, gingival bleeding, gingival sores, weeping/bleeding sores |Psych: mood disorders, depression, anxiety, suicidal ideations, suicidal attempts |GU: hematuria, pain, discharge, itching. Change in: urgency, frequency"][text size=50]
[checkbox name="variable_17" value="No relevant risk factors|Risk factor of Sun exposure|Risk factor of intermittent sunscreen use|Risk factor of Chemical exposure |Risk factor of IV drug use |Risk factor of Recent travel |Risk factor of Hobbies"] [text size=50]
[mark name="Social History"]
Social History:
[checkbox name="variable_18" value="Allergies to Drugs: Yes|Allergies to Drugs: No|Tobacco Use: Yes|Tobacco Use: No |Alcohol Use: No |Alcohol Use: Yes |Married|Divorced|Widow/Widower|Single|Children: Yes|Children: No|Service: Army|Service: Air Force|Service: Navy|Service: Marines|Service: Other|Pacemaker: Yes|Pacemaker: No|Defibrillator: Yes|Defibrillator: No"][text size=50]
OBJECTIVE:
Physical Exam:
General:The veteran is a [checkbox name="variable_19" value="Well Appearing|Ill Appearing|Healthy|Obese|Male|Female|In no acute distress|In acute distress"] 
Skin/Extremities: Inspected Skin of [checkbox name="variable_20" value="Face,Neck,Scalp,Chest,Abdomen,Back,and Upper Extremities including the Palms and Nail beds of the Fingers|Buttocks|Genitals|Breasts|Lower Extremities including Soles and Nail beds of the Feet"] [text size=50]
Dermatological Findings:
[comment memo="Steroid Atrophy: "][checkbox name="Variable_81" value="Hypopigmentation, prominence of underlying veins, thinning of skin, erythematous/purple striae. "]
[comment memo="Actinic Keratosis: "][checkbox name="Variable_21" value="Erythematous, hyperkeratotic papules with scaling. "]
[comment memo="BCC vs other: "][checkbox name="Variable_22" value="Pearly pink papule with telangiectasias. "]
[comment memo="Chronic eczematous inflammation: "][checkbox name="Variable_23" value="Confluent erythema with scaling and occasional crust and fissuring. "]
[comment memo="Hand Eczema: "][checkbox name="Variable_24" value="Erythema of palms with excoriations, scaling, and pruritus. History of irritant contact. "]
[comment memo="Ecchymosis: "][checkbox name="Variable_25" value="Greater than 1 cm erythematous or purple macules. "]
[comment memo="Hypertrophic scar: "][checkbox name="Variable_26" value="Excess scar tissue growth that does not overgrow the original wound boundaries. "] 
[comment memo="Keloid: "][checkbox name="Variable_27" value="Growth of excess scar tissue that overgrows the original wound boundaries.
[comment memo="Lichen simplex chronicus: "][checkbox name="Variable_28" value="Purple, papules, polygonal, excoriations, scales, Reticular lines on flexor surfaces (history of scratching). "]  
[comment memo="Milium: "][checkbox name="Variable_29" value="Small superficial cyst containing keratin, 1-2mm in size. "]
[comment memo="Neurofibroma: "][checkbox name="Variable_30" value="Spongy flesh colored nodule. "] 
[comment memo="Papilloma: "][checkbox name="Variable_82" value=" "]
[comment memo="Petechiae: "][checkbox name="Variable_31" value="1-2 mm erythematous or purple macules that do not blanch with pressure. "] 
[comment memo="Purpura: "][checkbox name="Variable_32" value="3-10 mm red or purple macules that do not blanch with pressure. "]
[comment memo=""][checkbox name="Variable_33" value=" "]
[comment memo="Solar lentigos: "][checkbox name="Variable_34" value=" "]
[comment memo="Seborrheic Keratosis: "][checkbox name="Variable_35" value="Skin-colored/brown macules or papules with warty or stuck on appearance. "]
[comment memo=""][checkbox name="Variable_36" value="Symmetric brown or pink, macules or papules 3-7mm. "]
[comment memo="Wart: "][checkbox name="Variable_37" value="Skin-colored/pink/brown hyperkaryotic papules with punctate hemorrhages. "]
[comment memo=""][checkbox name="Variable_38" value=" "]
[comment memo=""][checkbox name="Variable_39" value=" "]
[comment memo="Wheals/Hives: "][checkbox name="Variable_40" value="Transient Less than 24 hours well-circumscribed, superficial edematous papules or plaques that are white to pale red and often appear and disappear over a period of hours."]
[link memo="Go to Procedures" mark="Procedures"]
[link memo="Go to Assessment and Plan" mark="Assessment and Plan"]
[comment memo="Macule: flat,non-palpable lesion, <1cm- Patch: flat,non-palpable lesion. >1cm (e.g., vitiligo,cafe au lait spot)-Papule: palpable lesion, elevated above the skin, <1cm (e.g., molluscum contagiosum, acne vulgaris)-Plaque: palpable lesion, elevated above the skin, >1cm (e.g.. psoriasis)-Vesicle: <1cm blister (e.g.. varicella, contact dermatitis)-Bulla: >1cm blister (e.g., bullous pemphigoid)-Pustule: superficial cavity of the skin that contains a purulent exudate (e.g., folliculitis)-Nodule: <1cm deep palpable solid lesion within the skin (e.g.. lipoma)-Tumor: >1cm nodule-Cyst-Wheal: rounded or flat-topped papule or plaque that is evanescent due to edema of the dermis (e.g., hives, angioedema): ADDITIONAL NOTE-TEXTURED PATTERN=BENIGN"]
[checkbox name="variable_42" value="Size, Location, Description, Features, and Grouping of Lesion 1: "][text size=50][checkbox name="variable_43" value="cm |mm |Right |Left |Proximal |Distal |Lateral |Medial |Dorsal |Ventral |Forehead |Vertex of Head |Temple |Cheek |Mandible |Tip of nose |Ala |Helix of ear |Anti-helix of ear |Tragus |Ear Lobe |Superior lip |Inferior lip |Upper arm |Forearm |Hand |Foot |1st digit |2nd digit |3rd digit |4th digit |5th digit |Epigastric |LUQ |LLQ |RUQ |RLQ |Suprapubic |Abdomen |Chest |Upper back |Mid back |Lower back |Buttocks |Penis |Scrotum |Labia majora |Labia minora |Macular |Patch |Paular |Plaque |Maculopapular |Nodule |Tumor |Ulcer |Vesicle |Bulla |Pustule |Erythematous |Leukoderma |Purpura |Hyperpigmentation |Hypopigmentation |Telangiectasia |Grouping: |Linear |Annular ringlike configuration |Grouped clustered lesions |Serpiginous wavy or serpent-like appearance |Reticular net-like arrangement |Target like a bull's eye |Discoid "] 
[checkbox name="variable_44" value="Size, Location, Description, Features, and Grouping of Lesion 2: "][text size=50][checkbox name="variable_45" value="cm |mm |Right |Left |Proximal |Distal |Lateral |Medial |Dorsal |Ventral |Forehead |Vertex of Head |Temple |Cheek |Mandible |Tip of nose |Ala |Helix of ear |Anti-helix of ear |Tragus |Ear Lobe |Superior lip |Inferior lip |Upper arm |Forearm |Hand |Foot |1st digit |2nd digit |3rd digit |4th digit |5th digit |Epigastric |LUQ |LLQ |RUQ |RLQ |Suprapubic |Abdomen |Chest |Upper back |Mid back |Lower back |Buttocks |Penis |Scrotum |Labia majora |Labia minora |Macular |Patch |Paular |Plaque |Maculopapular |Nodule |Tumor |Ulcer |Vesicle |Bulla |Pustule |Erythematous |Leukoderma |Purpura |Hyperpigmentation |Hypopigmentation |Telangiectasia |Grouping: |Linear |Annular ringlike configuration |Grouped clustered lesions |Serpiginous wavy or serpent-like appearance |Reticular net-like arrangement |Target like a bull's eye |Discoid "]
[checkbox name="variable_46" value="Size, Location, Description, Features, and Grouping of Lesion 3: "][text size=50][checkbox name="variable_47" value="cm |mm |Right |Left |Proximal |Distal |Lateral |Medial |Dorsal |Ventral |Forehead |Vertex of Head |Temple |Cheek |Mandible |Tip of nose |Ala |Helix of ear |Anti-helix of ear |Tragus |Ear Lobe |Superior lip |Inferior lip |Upper arm |Forearm |Hand |Foot |1st digit |2nd digit |3rd digit |4th digit |5th digit |Epigastric |LUQ |LLQ |RUQ |RLQ |Suprapubic |Abdomen |Chest |Upper back |Mid back |Lower back |Buttocks |Penis |Scrotum |Labia majora |Labia minora |Macular |Patch |Paular |Plaque |Maculopapular |Nodule |Tumor |Ulcer |Vesicle |Bulla |Pustule |Erythematous |Leukoderma |Purpura |Hyperpigmentation |Hypopigmentation |Telangiectasia |Grouping: |Linear |Annular ringlike configuration |Grouped clustered lesions |Serpiginous wavy or serpent-like appearance |Reticular net-like arrangement |Target like a bull's eye |Discoid "]
[checkbox name="variable_48" value="Size, Location, Description, Features, and Grouping of Lesion 4: "][text size=50][checkbox name="variable_49" value="cm |mm |Right |Left |Proximal |Distal |Lateral |Medial |Dorsal |Ventral |Forehead |Vertex of Head |Temple |Cheek |Mandible |Tip of nose |Ala |Helix of ear |Anti-helix of ear |Tragus |Ear Lobe |Superior lip |Inferior lip |Upper arm |Forearm |Hand |Foot |1st digit |2nd digit |3rd digit |4th digit |5th digit |Epigastric |LUQ |LLQ |RUQ |RLQ |Suprapubic |Abdomen |Chest |Upper back |Mid back |Lower back |Buttocks |Penis |Scrotum |Labia majora |Labia minora |Macular |Patch |Paular |Plaque |Maculopapular |Nodule |Tumor |Ulcer |Vesicle |Bulla |Pustule |Erythematous |Leukoderma |Purpura |Hyperpigmentation |Hypopigmentation |Telangiectasia |Grouping: |Linear |Annular ringlike configuration |Grouped clustered lesions |Serpiginous wavy or serpent-like appearance |Reticular net-like arrangement |Target like a bull's eye |Discoid "]
[checkbox name="variable_50" value="Size, Location, Description, Features, and Grouping of Lesion 5: "][text size=50][checkbox name="variable_51" value="cm |mm |Right |Left |Proximal |Distal |Lateral |Medial |Dorsal |Ventral |Forehead |Vertex of Head |Temple |Cheek |Mandible |Tip of nose |Ala |Helix of ear |Anti-helix of ear |Tragus |Ear Lobe |Superior lip |Inferior lip |Upper arm |Forearm |Hand |Foot |1st digit |2nd digit |3rd digit |4th digit |5th digit |Epigastric |LUQ |LLQ |RUQ |RLQ |Suprapubic |Abdomen |Chest |Upper back |Mid back |Lower back |Buttocks |Penis |Scrotum |Labia majora |Labia minora |Macular |Patch |Paular |Plaque |Maculopapular |Nodule |Tumor |Ulcer |Vesicle |Bulla |Pustule |Erythematous |Leukoderma |Purpura |Hyperpigmentation |Hypopigmentation |Telangiectasia |Grouping: |Linear |Annular ringlike configuration |Grouped clustered lesions |Serpiginous wavy or serpent-like appearance |Reticular net-like arrangement |Target like a bull's eye |Discoid "]
[mark name="Procedures"]
[checkbox name="Procedure" value="Shave Biopsy: 
• Verbal and written consent obtained
• Nurse took photograph of site:
• Site Cleansing: ETOH
• Local anesthesia: 1% Lidocaine HCL w/epi 1:100K
• Biopsy per shave technique
• Hemostasis obtained with AlCl
• Area then cleansed
• Petroleum jelly and a band aid applied
• Confirmation was obtained by visual inspection then biopsy tissue was sealed specimen bottle
• Verbal and written wound care instructions provided
• I told the veteran I would call with the biopsy results
• I instructed the veteran that is the veteran did not hear from me within 7-10 days with the results that the veteran call me (Phone # and extension provided on wound care written instructions). 
|Punch Biopsy: 
• Verbal and written consent obtained
• Nurse took photograph of site: 
• Site Cleansing: ETOH
• Local anesthesia: 1% Lidocaine HCL w/epi 1:100K
• Biopsy per punch technique
• mm: 
• Hemostasis obtained with placement of suture
• Suture type:
• Area then cleansed
• Petroleum jelly and a band aid applied
• Confirmation was obtained by visual inspection then biopsy tissue was sealed specimen bottle
• Verbal and written wound care instructions provided
• I told the veteran I would call with the biopsy results
• I instructed the veteran that is the veteran did not hear from me within 7-10 days with the results that the veteran call me (Phone # and extension provided on wound care written instructions). 
• Veteran instructed that suture removal would be in 
|EDC: 
• Written/computer consent done
• Site Cleansing: ETOH
• Local anesthesia: 1% Lidocaine HCL w/epi 1:100K
• EDCX3 with 7mm and 4mm disposable curette with margin mm 
• Cleansing: ETOH
• Bandage: Vaseline, bandage
• Verbal and written wound care instructions provided
• Final size:
|Shave/EDCX3:
• Verbal and written consent obtained
• Nurse took photograph of site: 
• Site Cleansing: ETOH
• Local anesthesia: 1% Lidocaine HCL w/epi 1:100K
• Biopsy per punch technique
• EDCX3 with 7mm and 4mm disposable curette with margin mm 
• Area then cleansed
• Petroleum jelly and a band aid applied
• Confirmation was obtained by visual inspection then biopsy tissue was sealed specimen bottle
• Verbal and written wound care instructions provided
• I told the veteran I would call with the biopsy results
• I instructed the veteran that is the veteran did not hear from me within 7-10 days with the results that the veteran call me (Phone # and extension provided on wound care written instructions)."] 
[mark name="Assessment and Plan"]
Assessment and Plan:
Diagnosis:
[textarea name="variable_52" default=""]
[checkbox name="Variable_53" value="Steroid Atrophy:|Actinic Keratosis: |Solar lentigos: |Seborrheic Keratosis: |symmetric brown or pink, macules or papules 3-7mm.|Wart: |Papilloma: |Milium:  |Petechiae: |Purpura: |Ecchymosis: |Wheals/Hives: |Hypertrophic scar: |Keloid: "]
[checkbox name="Variable_54" value="Medications Prescribed: |option B|option C"]
[checkbox name="variable_55" value="Dermatitis Tx: 
• Moisturizer BID every day (lotions, creams, or ointments)
• The best time for application of a moisturizer is after bathing and showering when skin is still damp
• The best moisturizer is petroleum jelly or an ointment
• The next best moisturizer is a cream
• The worst is a lotion due to having alcohol; therefore, they dry the skin

Good choices for cleansers/moisturizers and shampoos are below (most of which are fragrance free)
• Cetaphil cleanser and cream
• Dove sensitive skin cleanser
• Dove Nutrium cleanser
• Cerave cleanser and cream
• Vanicream cleanser and cream
• Free and clear shampoo and conditioner

For patches of dermatitis:
• Topical steroids is appropriate for a specified time (this helps reduce side effects of tachyphylaxis, skin thinning/atrophy-as evidenced by shiny skin/telangiectasia/striae/skin tearing/purpura; folliculitis/acne; and rarely significant systemic absorption).   
• Different topical steroids, possibly different dosages, and different delivery methods (lotion, gel, cream, and/or ointment) may be used on different parts of the body."]
[checkbox name="variable_56" value="Seborrheic Dermatitis of face Tx: 
• Ketoconazole cream BID PRN to areas of involvement with scaling. "]
[checkbox name="variable_57" value="Seborrheic Dermatitis of Scalp Tx: 
• Shampoo at least 3-4x/week with below medicated shampoo
• Longer period of lathering (5+ minutes)
• If one wants to shampoo daily, that is fine, but use your non-medicated shampoo(s).
• If one wants to shampoo with your non-medicated shampoo after using below, for instance, because you like the smell of the non-medicated shampoo that is fine.
• Recommended shampoos for SD are below and one should use:
• One of them 3x/week
Ketoconazole shampoo MWF for scalp shampoo, and if after 6 weeks no improvement move to next step
• Two of them alternating every other month and using 3x/week
Shampoos:
Ketoconazole, Salicylic acid, Selenium containing, Zinc containing
Selenium sulfide (2.5%), ketoconazole shampoos may help by reducing (Malassezia) yeast scalp reservoirs. Shampoos many be used on truncal lesions or in beards but may cause inflammation in the intertriginous or facial areas. 
****Topical corticosteroids may hasten recurrences, may foster dependence because of rebound effect, and are discouraged except for short-term use. "]
[checkbox name="variable_58" value="Sun damaged skin Tx: 
• Photoprotection daily
• SSE monthly
• Veteran advised that is will be their responsibility to both make and keep dermatology appointments."]
[checkbox name="variable_59" value="Tinea Cruris Tx:
• Apply topical antifungal cream BID for the designated time by your health care provider
• Put sox on before underwear, so as not to drag foot fungus up to skin of groin
• Wash hands after touching feet/clipping toenails
• Use shower thongs
• If after appropriate treatment for time allotted by healthcare provider, the condition has not resolved, please be revaluated by your healthcare provider as there are several conditions that may look/act similar to TC"]
[checkbox name="variable_60" value=" Tx:  "]
[checkbox name="variable_61" value=" Tx:  "]
[checkbox name="variable_62" value=" Tx:  "]
[checkbox name="variable_63" value=" Tx:  "]
[checkbox name="variable_64" value=" Tx:  "]
[checkbox name="variable_65" value=" Tx:  "]
[checkbox name="variable_66" value=" Tx:  "]
[checkbox name="variable_67" value=" Tx:  "]
[checkbox name="variable_68" value=" Tx:  "]
[checkbox name="variable_69" value=" Tx:  "]
[checkbox name="variable_70" value=" Tx:  "]
[checkbox name="variable_71" value=" Tx:  "]
[checkbox name="variable_72" value=" Tx:  "]
[checkbox name="variable_73" value=" Tx:  "]
[checkbox name="variable_74" value=" Tx:  "]
[checkbox name="variable_75" value=" Tx:  "]
[checkbox name="variable_76" value=" Tx:  "]
[checkbox name="Variable_77" value="At Home Care: |Gently massage thin layer of prescribed topical medication onto affected area. |Use sunscreen daily. |Use protective clothing with wide brimmed hat daily. |Every Day |BID |TID |Every other day |MWF |M-F "]
[textarea name="variable_78" default=""]
[checkbox name="Variable_79" value="Referral to: |ENT |Surgeon"]
Return to Clinic:
[checkbox name="Variable_80" value="3 Months |6 Months |1 Year"][text size=10]