Dermatology for VA

SUBJECTIVE:
[text default="CC:" size=100]
HPI:
[text size=5] year old [select value="male|female"] [checkbox name="variable_1" value="presents with a previous history of: |Melanoma. |Non-Melanotic Skin Cancer. "][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_35" 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_13" default=""]
Medications:
[textarea name="variable_11" default="Reviewed Medications; No medications are relevant to current skin condition."]
[checkbox name="variable_12" value="Family History of Melanoma. "][text size=50]
[checkbox name="variable_14" value="Skin ROS: No other skin rashes or lesions of  complaint apart from above. "][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"][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]
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 "]
Psych: [checkbox name="variable_21" value="A&O x 3 |Cooperative |Uncooperative |Euthymic |Dysthymic |Upset "] 
Skin/Extremities: Inspected Skin of: [checkbox name="variable_20" value="Hair, Face, Neck, Scalp, Oral Mucosa, 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="Scars: "][checkbox name="variable_22" value="All scars are unremarkable. No nodularity and no concerns for reoccurrence. "]
[comment memo="Photo Damage: "][checkbox name="variable_23" value="Photo damage of the head and extremities. "]
[comment memo="Actinic Keratoses: "][checkbox name="variable_24" value="Multiple hyperkeratotic papules with thick adherent scales."][text size=50]
[comment memo="Cherry Angiomas: "][checkbox name="variable_25" value="Multiple Cherry colored macules."][text size=50]
[comment memo="Seborrheic Keratoses: "][checkbox name="variable_26" value="Multiple tanned/hyperpigmented stuck on appearing papules."][text size=50]
[link memo="Go to Procedures" mark="Procedures"]
Assessment and Plan:
Diagnosis:
[textarea name="variable_27" default=""]
[comment memo="Common Diagnoses with Plans"]
[checkbox name="Variable_28" value="Dx: Actinic Keratoses-
Discussed treatment with cryotherapy as well as risks and benefits including the possibility of incomplete treatment or recurrence as well as scarring/dyspigmentation. Encouraged patient to return to clinic should lesions not resolve following treatment. 
*** lesions treated with cryotherapy today."]
[text size=50]
[checkbox name="variable_61" value="Dx: Cherry Angiomas-
Reassured regarding the benign nature of these growths."]
[checkbox name="variable_30" value="Dx: Dermatitis- 
• 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_31" value="Dx: Seborrheic Dermatitis-
Treatment for Face/Body: 
• Ketoconazole cream BID PRN to areas of involvement with scaling. "]
[checkbox name="variable_32" value="Dx: Seborrheic Dermatitis- 
Treatment for Scalp: 
• 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_60" value="Dx: Seborrheic Keratoses-
Reassured regarding the benign nature of these growths."]
[checkbox name="variable_33" value="Dx: Sun damaged skin-
• Photoprotection daily
• SSE monthly
• Veteran advised that is will be their responsibility to both make and keep dermatology appointments.
• Will return for regularly scheduled skin examination or sooner for any concerns."]
[checkbox name="variable_34" value="Dx: Tinea Cruris-
• 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"]
[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)."] 
Return to Clinic:
[checkbox name="Variable_80" value="3 Months |6 Months |1 Year"][text size=10]