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Dermatology SOAP Note Medical Transcription Samples

SUBJECTIVE:  The patient is a (XX)-year-old woman who returns for followup of rosacea and because of history of lichenoid keratosis. The patient reports that once every couple of months, the rosacea flares. She then started to use Noritate cream and sodium sulfacetamide, and within a month, she reports it has calmed down. The patient does not use the medications on a regular basis.  Moderate sun exposure. She does use sunscreen for outdoor activities.

OBJECTIVE:  The patient is alert and oriented x3. On examination of her face, neck, chest, abdomen, back, upper and lower extremities, hands, feet bilaterally, there are no worrisome pigmented lesions or other lesions worrisome for cutaneous malignancy. Face shows mild erythema on the forehead and cheeks.

ASSESSMENT:  Mild rosacea, history of actinic keratosis.

PLAN:  We discussed with the patient that she will see fewer flares of the rosacea if she uses the metronidazole 0.75% cream daily. The patient can increase to b.i.d. if it does flare. She can continue with the sodium sulfacetamide daily on a p.r.n. basis. Follow up in one year.

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SUBJECTIVE:  The patient is a (XX)-year-old woman who returns four weeks after beginning narrow-band UVB for chronic eczema. The patient’s eczema worsened significantly as she was tapering prednisone. She is now back to 20 mg prednisone daily; it had been tapered down to 7.5 mg. The patient is using clobetasol ointment on her skin. She does note that the itchiness has lessened, but she does not think the eczema has improved since she started phototherapy. She is presently on prednisone 20 mg daily, clobetasol ointment daily, hydroxyzine 10 mg q. 6 hours, betamethasone valerate lotion to the scalp, and desonide cream to the face p.r.n.

OBJECTIVE:  The patient is alert and oriented x3. There are erythematous, slightly lichenified coalescing papules on the upper mid back, abdomen, proximal thighs, and arms. Face is clear.

ASSESSMENT:  Chronic eczema.

PLAN:  The patient will continue with the narrow-band UVB for an additional four weeks. We discussed with the patient if at that point she really has not had any improvement in her eczema, then it is unlikely that continuing phototherapy is going to be beneficial. We discussed with her again today that the phototherapy is not curative, but can have an additive benefit through other medications in managing the eczema. The patient voiced understanding of this, and she will continue with the narrow-band UVB three times weekly. Followup will be in four weeks.

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SUBJECTIVE:  The patient is a (XX)-year-old gentleman who returns for skin examination because of a history of basal cell carcinoma. He questions raised moles on his back, chest, legs; all of these are asymptomatic.

OBJECTIVE:  The patient is alert and oriented x3. On examination of his face, neck, chest, abdomen, back, upper and lower extremities, hands, feet bilaterally, he has sebaceous hypertrophy diffusely on the dorsal and distal aspect of the nose. There are no inflammatory papules or pustules seen. There are multiple tan brown and gray stuck-on keratotic papules and plaques widely scattered on the back, chest, and legs; none with worrisome features.

ASSESSMENT:  Multiple seborrheic keratoses. No sign of new basal cell carcinoma, rosacea with rhinophyma changes.

PLAN:
1.  The patient wants to try stopping the tetracycline. We discussed with him the rosacea may have remitted. On the other hand, we discussed with him if he does start developing new areas of redness, pustules on the nose, would recommend resuming the tetracycline 500 mg p.o. b.i.d. He voiced understanding of this. He was given a written prescription, so can restart the medication if needed.
2.  Reassurance regarding all of the other skin lesions he questions. Follow up again in one year because of a basal cell carcinoma.

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SUBJECTIVE:  The patient is a (XX)-year-old woman who returns for followup of hand eczema. She is very pleased with the improvement in her skin and has no other complaints regarding her skin today.

OBJECTIVE:  The patient is alert and oriented x3. Palmar surface of right, greater than left hand, shows mildly erythematous, dry patches and similar changes on the dorsal surface of several of the fingers.

ASSESSMENT:  Atopic eczema with component of chronic irritant contact dermatitis, improved.

PLAN:
1.  Encouraged her to continue and increase moisturizer as her skin is still quite dry.
2.  Continue with the mometasone ointment b.i.d. to the eczematous areas.
3.  We discussed with her if it becomes severe, she can resume the clobetasol ointment, but not for longer than two weeks continuously. Followup is p.r.n.

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