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Facial Rash Dermatology Consultation MT Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Facial rash.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female with no significant past medical history, who presents with a complaint of 2-year history of facial rash described as a red blotchiness area on both cheeks running down along the labial fold to the chin and superior in between the eyebrows. This is associated with severe dryness, redness, worsening with dry season such as wintertime. The patient describes scaly-like flakes that she can then flake off or scratch off from her cheeks bilaterally. She does not feel that this worsens with emotional stress or with heat. She denies that this worsens with alcohol, sun, or heat. The patient denies feeling flushed at times of stress and embarrassment. She currently is not having menopausal symptoms and does not notice any other modifying factors besides dry weather or windy weather as well.

PAST MEDICAL HISTORY:  The patient had surgery on her eyes bilaterally as a child as she was crossed eyed and had tympanostomy tubes placed when she was a child as well.

ALLERGIES:  Pollen in spring and fall.

MEDICATIONS:  Multivitamin.

SOCIAL HISTORY:  The patient does not drink or smoke tobacco. Denies IV drug use.

FAMILY HISTORY: No family history of skin cancer. No family history of lupus. Father is in good health. Mother has hyperlipidemia. She has one brother and two sisters. Her elder sister has hypertension.

REVIEW OF SYSTEMS: The patient denies fevers, chills, nausea, vomiting, or diarrhea. She currently does not have an exacerbation of allergies; however, she does have seasonal allergies during the spring and fall, likely to pollen. Currently, no rhinorrhea, postnasal drip, no sore throat, no difficulty breathing. The remainder of her review of systems is completely negative. The patient denies any possibility of currently being pregnant.

PHYSICAL EXAMINATION:
VITAL SIGNS:  The patient is afebrile, weight 208 pounds, height 5 feet 7 inches. Vital signs are stable.
GENERAL:  The patient is awake, alert, and oriented x3, in no acute distress; appears comfortable and appears stated age. She is obese. Her mood is pleasant.
SKIN:   Skin type is level II. Pertinent skin exam findings include, across the patient's face, on her cheeks bilaterally, there appears to be 1 to 2 mm erythematous or red papule, as well as across the patient’s chin and between eyebrows. This appears to be in a rosacea-type pattern. Over the extensor surface of her upper left upper extremity, the patient appears to have raised pigmented lesion with regular borders and homogeneous coloration, approximately 3 to 4 mm in diameter. The patient appears also to have multiple cherry angiomas across her upper chest, as well as upper torso on her back with some flat pigmented lesions across her back as well and two on her inner thigh of her left lower extremity. Otherwise, physical exam appears to be completely within normal limits.

ASSESSMENT AND PLAN:  The patient is a (XX)-year-old female who comes in with a complaint of 2-year history of a facial rash that apparently has significantly improved over the last 2 to 3 weeks.
1.  Facial rash:  This is likely rosacea since the patient's pattern is consistent with rosacea. However, the story is not typical for rosacea. The patient does not have frequent flushing and does not appear to notice if it is worse with emotional stress, alcohol, or spicy foods. However, physical exam findings are consistent with rosacea. Seborrheic dermatitis was also considered in the patient's differential diagnosis because of the scaly nature of her description; however, the patient denies noticing this rash extending into the ear or around the ear and does not appear to follow the typical pattern of seborrheic dermatitis. The patient denies pruritus with exacerbation of the facial rash. Therefore, this is not likely atopic dermatitis. This was discussed with the patient, about trying to further monitor exacerbating factors for her rosacea and when this is discovered to attempt avoidance of these modifying factors. We also prescribed her a 3 gram tube of MetroGel to be applied to her face b.i.d. until complete resolution of her facial rash.
2.  Junctional nevi:  There appears to be some multiple junctional nevi across the patient's back.
3.  Complex nevi:  There appear to be complex nevi over the extensor surface of her left upper extremity.
4.  Cherry angioma:  There appear to be a few cherry angiomas across the patient’s chest and upper back torso, all of which appear benign in nature.

The patient was seen in consultation at the request of Dr. Doe.

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