DERMATOLOGY TEST FILES

DERMO_T1

Dermatology

CHART NOTE

Returns today.

Zoster still quite active.  No new blisters forming.  Still has many active vesicles present.

Because there is still active dermatitis, it is too early to start Zostrix.  I will maintain her Darvocet-N 100 (she has a refill), hydroxyne 50 mg one-half hour prior to bedtime for sleep.  We will initiate a gradual Prednisone taper, 40 mg q.a.m. for the next 5 days, 20 mg q.a.m. for 5 days, 10 mg q.a.m. for 5 days.  Patient was advised to carefully check her sugar levels, since they may begin to drop as the Prednisone dose is weaned.  She is currently on insulin because of aggravation of her diabetes.  She is to recheck with me in 2 weeks.

At that time, provided she is minimally symptomatic, I will plan to taper her fairly rapidly off of the remaining prednisone and initiate topical Zostrix therapy.

CHART NOTE

Returns today.

Oral cavity, especially the cheeks and labial mucosa, are improved.  Soles have been improved.  Palms have improved but are still painful because of fissures.  Main problem is the lower lip, which is still denuded and is showing some granulation tissue where it had been de-epithelialized by the disease.  He is to remain on Accutane 50 mg per day; prescription given.  He has no history of hypertension, ulcers, diabetes, glaucoma, or tuberculosis.  I will therefore place him on a short burst of Prednisone to try and get the disease under better control.  He is to take 40 mg q.a.m. for 3 days, 20 mg x 3 days, 10 mg x 3 days, 5 mg x 3 days, 2.5 mg x 4 days, and then off.  He is to continue the use of Lidex ointment to the lower lip, Lidex ointment covered with urea cream to the palmar and plantar lesions.  He is to recheck in 3 weeks for follow-up.  Lab work on the Accutane will be obtained at that time.

CHART NOTE

She is 11 years of age and is here today with her parents regarding 2 problems.

1.  A thick scar on the left upper lip adjacent to the nasolabial fold.  This was form excision of a mole.  This was done a year ago.

The scars thickened almost immediately.

On examination today there is a hypertrophic spread scar on the left upper lip following the contour of the nasolabial fold.  It measures are approximately 1.2 x 5.5 cm.  It is at the present time relatively quiescent, uninflamed, and nonsymptomatic.

DISPOSITION:  I have recommended no active therapy unless the scar begins to enlarge.  Provided it is stable, I advised them to watch it for a couple of years before considering any sort of reparative procedure.  If it is acceptable at that time, I would leave it alone; otherwise, consult with me again considering a possible repair.  I advised them, however, that even under the best of circumstances, any attempt at revision could result in more scar formation.

2.  On her right mid lower back she has a 5 mm medium-brown, clinically benign, sharply marginated, evenly colored nevus, dermal in character, with normal skin lines.  This lesion has been subject to repeated trauma.  The parents wish it gone.

I have explained to them both at length the difference between shave and excisional removal.  The mother was already familiar with it.  I have warned them about them about the possibility of thick scar formation, which they accept.  After a full explanation, at their request the lesion was shave excised and submitted for microscopic examination.  Because of tendency towards thick scar formation, I have asked them to recheck in 1 month so that I can look at it, immediately if any difficulties are encountered.

CHART NOTE

Returns today.

Patch tests to cosmetics are negative.  Eruption is clear.  Patient is to recheck if there are any further difficulties.  She was advised that she may resume the use of her cosmetics.  This appears to be simply a localized atopic eczema.

CHART NOTE

Returns today.

She was doing well, then had a sudden exacerbation of her dermatitis 3 days ago.

Examination today reveals now an acute eczematous dermatitis which for the first time shows a fairly definite pattern over her buttock area, low midback, and shoulders.  I have again gone through her history for possible contactants.  We have already gone through her laundry products; these have been either eliminated or changed.  History reveals that the flairing occurred about a day after she restarted her aerobic classes.  For these classes she wears a stretch spandex suit.  In addition, I examined her underwear today; they are of a heavy stretch type, they contain 12% spandex, and portions of her brassiere panels contain 16% spandex.

Patients are often allergic to the rubber chemicals in these products.  It would appear that she probably has a rubber chemical sensitivity, specifically to the product spandex.

I have recommended that she have eliminate temporarily all spandex-containing clothes, anything that is elastic or stretchy, and in particular she is to also examine her bathing suit.  Temporarily switch to cotton underwear with as little elastic product as possible will, do not bleach them, and be sure that they do not contain brand-name spendix.  Given a new supply for triamcinolone cream, 2 ounces plus 3 refills, 0.1%, use t.i.d. and p.r.n. itch till clear.

As soon as her dermatitis has settled down, I plan to patch test her to cuttings from the actual products plus the rubber chemicals.  Fortunately, the history and pattern of dermatitis were more specific today.

CHART NOTE

a 31-year old woman who has had a chronic problem with tinea pedis and onychomycosis.  Was treated with oral griseofulvin.  The griseofulvin cleared her feet, but she developed a generalized rash and allergic reaction to the drug before she was able to achieve clearing of her toenails.

Approximately a year and a half ago she saw Dr. (blank) and was treated with multiple topical agents including miconazole, Nizoral,and Loprox, with no significant result.  It is noted, however, that the patient only used the Loprox for about 3 months, and no debridement was done.

On examination today she presents with an onychomycosis involving about 60% of the right great toenail.  The right fourth and fifth nails and left second and fifth nails are involved to the base.  The other nails, toe webs and soles are clear.  The findings are consisted consistent with a dermatophyte infection.

IMPRESSION

1.  Tinea Pedis by history, currently clear.

2.  Onchomycosis involving 5 of 10 toenails.

DISPOSITION:  I have explained to her the other alternative medication, ketonazole, and I have warned her about its potential serious liver toxicity, advising her that there have been some rare but significant reaction with jaundice, prolonged recovery times, and 1 reported death.  I advised her that these reactions are quiet rare, about 1 in 15,000 patients, and if she desires an alternative agent to try and treat the nails, this would be at the present time our only available medication.  She indicated that her nails are painful and interfering with walking and that she does desire, if possible, to try and clear them.  Therefore, I have placed on her on Nizoral 200 mg per day, 45 dispensed plus no refill.  A chemistry panel is to be done prior to onset of therapy, 3 weeks from now, and she is to return for follow-up in 6 weeks.