VA

# Hypertrophic scar

HPI: protruding scar at site of prior trauma. patient says it is a little itchy

and feels tight.

PE: exophytic pink papule on left post neck

Plan:

- Options for treatment discussed. Patient elects to proceed with intralesional

kenalog injection.

- Procedure: ILK 10 mg/mL injected into 1 lesion on left posterior neck.

 

_________________________________________________________________________________________________

Patient was called to discuss his/her upcoming * appointment.

 

Reason for scheduled face-to-face appointment:

 

Patient was given option of converting to a telephone appointment. Patient

provided verbal consent to proceed with phone visit. Patient's phone number and

mailing address were confirmed per protocol.

 

PHONE ENCOUNTER:

Chief complaint:

 

HPI:

 

Assessment/Plan:

 

 

Given current COVID pandemic, discussed with patient about returning to clinic

in 2-3 months given there are no urgent issues today. He is amenable to this

plan.

 

Patient was discussed with Dr.

 

A total of # minutes were spent on this encounter.

_________________________________________________________________________________________________

 

# Acne, primarily inflammatory

PLAN:

- Continue fluconazole 400mg weekly

- Stop doxycycline due to nausea

- Consider starting Yaz or similar birth control, and perhaps spironolactone,

under supervision of PCP due to child bearing age

- Decrease skim milk/dairy

- Start the following topical regimen-

Morning:

Wash face with benzoyl peroxide (Panoxyl 3-4%, available at Walmart or target)

Apply clindamycin lotion

Apply moisturizer/sunscreen (ie CeraVe, cetaphil)

 

 

- Patient does not want further treatment since he thinks the cancer is all

gone. I explained that standard of care for this location and cancer type is

surgical removal. Discussed in detail with patient the possible outcomes of no

treatment, such as local growth of tumor, destruction and invasion of

skin/tissue/bone and other anatomic structures, and rare chance of metastasis.

Explained that ultimately we cannot force care onto the patient, but that he

needs to express understanding of consequences of no treatment. He verbalized

understanding. He will strongly consider seeing the outside Mohs surgeon for

treatment.

 

 

# Tinea pedis

HPI: itchy rash with scaling, maceration, and odor on the feet. present months.

no prior treatment.

PE: scaly plaques in a moccasin distribution on b/l feet, with maceration in

between toes

Plan:

- topical Lamisil, apply BID until rash is gone

 

 

#Folliculitis

HPI: Bumps on the neck and upper back, frequently come and go. Sometimes tender.

Previous treatments: body wash.

PE: multiple erythematous pustules on the posterior neck, back, and chest

Plan:

- Rx'd benzoyl peroxide 10% gel to affected areas

 

 

# Scabies, treated

HPI: Itchy rash for months. Not painful. Does wake him up at night. Wife has

same symptoms. Has noticed little red bumps on his body. Does not live in a

nursing home or other shared living. Did move into a new home in Sacramento

recently. No new soaps or detergents.

Interval 7/17/2019: Patient was prescribed Ivermectin 15mg to take on day 0 and

day 7. However, he only took the first dose. The rash came back and was even

itchier than before, so he went to ER and got permethrin. He applied that twice,

one week apart, and so did his wife, and he has been doing much better (much

less itchy). His rash has resolved and now he has some sores that are slowly

healing.

PE: scattered 0.5-1cm pink papules with brown base, some excoriated, on the

thighs, stomach, and groin.

ASSESSMENT: Consistent with post-scabetic dermatitis and PIH.

PLAN:

- Patient advised that re-infestation is possible. He should wash all laundry

with hot water and seal any items that cannot be washed for 2-3 days in airtight

bags (scabies mite cannot survive more than 3 days away from human skin).

Recommend treating any other close contacts at home (wife has already been

treated). He should go to ER or schedule urgent follow up with us if rash

recurs.

- hydrocortisone cream 1% prn for itch

 

 

# Xerosis

HPI: dry skin for many months, itchy, mainly on the arms, legs, and trunk.

PE: dry flaky skin on the arms, legs, back

Plan:

- Eucerin cream neck down 2+ times per day

 

________________________________________________________________________________________________

Diagnosis:

Body site:

Type of treatment: nbUVB

Frequency:

Dose: per protocol

Skin type: Fitzpatrick I

Consent obtained: Yes

Ophthalmologic exam (for PUVA): n/a

 

 

# Benign Nevi

HPI: brown spots on the skin for many years, none new or changing. No prior

treatments.

PE: multiple brown macules on the back and trunk, with benign appearance on

dermoscopy.

A/P:

- Benign nature reviewed.

- Discussed sun protection with sunscreen and long sleeves. Return if any

changing, growing, new or concerning lesions.

 

 

Dx: Venous stasis dermatitis

PE: 2+ pitting edema of the lower extremities and xerosis, hemosiderin

deposition

- Start AmLactin 5% daily

- Talk to PCP about increasing diuretic dose.

- emphasized exercise and wearing stockings

 

 

# Hx of NMSC

HPI: history of numerous other NMSC, see above.

PE: well healed scars

Plan:

- no e/o recurrence today

- continue regular skin checks

 

 

# Pruritus NOS

HPI: Pt c/o generalized itch. Wakes up in middle of night itching. Normal ROS.

No new meds, soaps, detergents, travel recently. No one at home has similar

itch. 

PE: diffuse xerosis

ASSESSMENT: Labs wnl. Normal renal and hepatic function. Normal TSH. All recent.

Likely culprit is xerosis and overwashing. However, differential remains wide

and includes developing systemic disorder such as malignancy or endocrine

deficiency, nutritional problem, etc.

PLAN:

- Emphasized importance of reducing frequency of soap use, decreasing number of

showers, and using tepid water.

- He should moisturize within 3 min of showering.

- Sarna lotion ordered today. Apply neck down at least once daily.

- Atarax 25mg qhs. SE of drowsiness discussed. Should not operate heavy

machinery.

- Cetirizine 10mg qam.

 

 

________________________________________________________________________________________________

# Acrochordons

HPI: growths on neck for many months. irritating, get caught on clothing.

PE: numerous flesh colored pedunculated lesions on the neck

Plan:

- Pt counseled on treatment options. RBA discussed. Elects to proceed with LN2

therapy. Expected blistering reaction explained.

- LN2 to *** lesions

________________________________________________________________________________________________

 

 

#Neoplasm of skin of uncertain behavior, r/o x

HPI: growth on x for several months. slowly growing. no prior

treatments.

PE:

Plan: Scoop Shave + EDC

PROCEDURE: Shave Biopsy + EDC

Location: ***

-Written informed consent obtained in the iMed system

-Area marked and photographed

-Local anesthesia achieved with infiltration of 1% buffered

lidocaine with 1:100,000 epinephrine local anesthetic.

-Dermablade used to perform a shave biopsy of the lesion, placed in formalin and

submitted to pathology for analysis

-Hemostasis achieved with electrocautery. The base of the wound was gently

curetted with a 4mm curette. Hemostasis again achieved with electrocautery.

-Vaseline and bandage applied, appropriate post-procedure care reviewed with the

patient.

 

________________________________________________________________________________________________

# Seborrheic dermatitis

HPI: Rash on face for many months. Mildly itchy and irritating.

PE: greasy scaling with erythema on forehead, nose, and chin

- Ketoconazole 2% shampoo 2-3 times a week, apply to all affected areas for 10-

15 minutes, then rinse.

- Hydrocortisone 1% cream eyebrows daily prn

 

 

 

EXAM: Examination of the scalp, ears, face, neck, chest, back, abdomen, and

upper and lower extremities, including the nails and fingers were normal except

for the findings documented in the integrated A/P. Patient declined

groin/buttocks exam.

 

_______________________________________________________________________________________________

S:

 

O:

- ill defined papule on the

 

Derm Path:

 

A/P: malignant lesion requiring EDC

 

Procedure Note: Electrodessication and curettage

Pre-op diagnosis: ***

Location: ***

Size:

Anesthesia: 1% lidocaine with 1:100K epinephrine

Amount: 3 mL

 

Before beginning the procedure a time out was performed to confirm the patient's

identity and the lesion's location. The area was prepped and draped in the usual

manner. Local anesthesia was obtained with a local infiltration of 1% lidocaine

with 1:100K epinephrine. Using a medium curette the clinically obvious tumor

was curetted vigorously followed by electrodessication with the electrogsurgical

unit. This procedure was repeated two more times. The wound was dressed with

bacitracin ointment and a band aid. Wound instructions were provided and the

patient was asked to follow up in derm clinic in 6-12 months.

 

Procedure was performed under supervision of ***.

 

#Neoplasm of uncertain behavior, r/o x

HPI: growth on x for several months. slowly growing. no prior treatments.

PE:

Plan: Skin Biopsy

SHAVE BIOPSY PROCEDURE NOTE

Location:

-Written informed consent obtained in the iMed system

-Area marked and photographed

-Local anesthesia achieved with infiltration of 1% buffered

lidocaine with 1:100,000 epinephrine local anesthetic.

-Dermablade used to perform a shave biopsy of the lesion, placed in formalin and

submitted to pathology for analysis

-Hemostasis achieved with aluminum chloride

-vaseline and bandage applied, appropriate post-procedure care reviewed with the

patient

 

______________________________________________________________________________________________

PUNCH BIOPSY PROCEDURE NOTE

 

-Written informed consent obtained in the iMed system

-Area marked and photographed

-Local anesthesia achieved with infiltration of 1% buffered

lidocaine with 1:100,000 epinephrine local anesthetic.

- 4-0 punch used to perform a biopsy of the lesion, placed in formalin and

submitted to pathology for analysis

-wound closed with 4-0 gut suture

-vaseline and bandage applied, appropriate post-procedure care reviewed with the

patient

 

 

 

# Actinic Keratoses

HPI: rough spots on face and arms for many months. has had similar spots

previously treated with LN2.

PE: gritty pink papules on the scalp, face, and arms

-Advised patient on the precancerous nature of these lesions and discussed

treatment options including LN cryotherapy, topical efudex/imiquimod and

photodynamic therapy. Patient elected to proceed with LN cryotherapy. RBA

discussed.

-After verbal consent was obtained, LN cryotherapy was performed today on a

total of *** lesions.

-Pt tolerated well. Advised on appropriate post-procedure care.

 

______________________________________________________________________________________________

#Verruca vulgaris

HPI: rough bump on skin for months, no pain or itch, no prior

treatments.

PE: verrucous papules

A/P:

-After verbal consent was obtained, LN cryotherapy was performed today on a

total of *** lesions.

-Pt tolerated well. Advised on appropriate post-procedure care.

 

 

 

# Seborrheic Keratoses

HPI: brown rough spots on trunk, face, and extremities for years. sometimes

itch.

PE: waxy stuck on appearing papules on face and trunk and extremities

-Advised on the benign nature and no need to treat unless irritated or

bothersome

- # irritated lesion(s) treated with LN cryotherapy today. SEs of

hypopigmentation and blister formation discussed.

 

_______________________________________________________________________________________________

S:

 

O:

 

Derm Path:

 

A/P:

 

Excision

 

Procedure:                         Excision with layered closure

Preoperative diagnosis:    ***

Location:                          Skin, ***

Preoperative size:                 *** cm

Postoperative length:     *** cm

Excision margins:                  *** cm

Anesthesia:                        Local, 1% lidocaine with 1:100,000

epinephrine

Amount:                            *** ml

Subcutaneous suture:       ***-0 Vicryl

Skin suture:                       ***-0 Fast-acting gut     

 

 

The patient was brought back to the minor surgical operatory. The procedure and

its risks, benefits, alternatives were explained. The patient appeared to

understand and signed an electronic consent form. The patient was placed in a

recumbent position. A time out was performed to verify the patient's identity

and the lesion location. Using a sterile surgical marking pen, a fusiform

ellipse was designed around the lesion, incorporating the margins described

above. Anesthesia was obtained with local infiltration of the solution described

above. The skin was incised with a scalpel to the layer of the subcutaneous fat

and the specimen was dissected sharply using curved iris scissors. The specimen

was submitted in formalin for histopathology. Hemostasis was maintained

throughout the procedure using the electrosurgical unit. Closure of the

subcutaneous tissue was obtained with buried, inverted, interrupted sutures. The

skin edges were approximated with a running suture. Bacitracin ointment and a

dry sterile pressure dressing were applied. The patient was also given verbal

and written wound care instructions. The patient ambulated from the minor

surgical operatory with no problems. Wound check prn. The patient will be

contacted with the pathology results.

 

Surgeon: ***

Dermatologic Surgery Resident: Dev Chahal, MD

Nurse: ***

 

_______________________________________________________________________________________________

 

Subject: Biopsy results

 

Dear ***

 

I have received the results from the biopsy/biopsies dated ***. The pathologist

has stated

that the biopsy showed a nonmelanoma skin cancer. As you know, a biopsy is not a

treatment for skin cancer: additional treatment is necessary.

 

Unless they are treated, skin cancers may grow larger and damage nerves, blood

vessels, and other vital skin structures. It is important to treat these spots

early to prevent problems and reduce scarring.

 

Sometimes, skin cancers will seem to disappear after the biopsy. This does not

mean that the skin cancer has gone away. It may still be hidden by the biopsy

scar or growing in deeper layers of the skin. Treatment is still necessary, even

if the spot looks like it's gone.

 

Please call to schedule additional treatment. Call either Theresa Furlong, RN,

our case manager, at 916-843-9068, or our main phone number, 916-366-5300.

 

 

_______________________________________________________________________________________________

Mohs Micrographic Surgery Report

 

Name: ***                 

Procedure#: ***

Diagnosis: ***

Location: ***                           

Pre-op Size: *** cm                            

Final Defect Size: *** cm

Stages: ***                                           

             

 

Indications for procedure: Ill-defined tumor margins, high-priority anatomic

location for preservation of normal tissue.

 

Mohs Procedure Report:

 

The patient was escorted to the outpatient surgical operatory. The proposed Mohs

procedure and reconstruction options were discussed with the patient. The risks,

benefits, and alternatives were discussed and the patient and the surgeon signed

an electronic consent form. A time out was taken to confirm the patient's

identity and the exact location of the skin cancer.

 

After the patient was placed in a recumbent position, the surgical site was

cleaned with chlorhexidine gluconate, draped, and infiltrated with 1% buffered

lidocaine with 1:100,000 epinephrine local anesthetic.

 

A sterile surgical marking pen was used to outline a thin margin of normal-

appearing skin around the tumor. A beveled incision was then made using a

scalpel. Small orienting nicks were made on the specimen and the surrounding

skin. The tissue was then sharply dissected from the surrounding skin.

Hemostasis was maintained with the electrosurgical unit. A temporary dressing

was placed on the surgical defect until the frozen section slides were

interpreted. The oriented specimen was placed in a Petri dish and transported to

the Mohs laboratory.

 

For each stage of the procedure, a visual representation of the specimen was

drawn on a Mohs map. This map graphically depicts the specimen's two-dimensional

appearance, orientation, and tissue preparation, which consists of dividing the

specimen and applying tissue dyes. Because the deep and peripheral portions of

the tissue are then embedded in the same geometric plane, the map also

represents an oriented scale drawing of the resulting histologic sections. The

Mohs technician then prepared frozen section slides using standard techniques.

The slides were stained with hematoxylin and eosin, and cover slips were

applied.

 

The frozen section slides were then examined under the microscope. If tumor was

found, it was localized on the map. The orienting nicks on the original specimen

corresponded to similar nicks on the surgical defect so areas of identified

tumor could be mapped back to the patient and resected. Additional layers of

removed skin were then processed as indicated above.  This iterative process

continued as applicable until no tumor was observed microscopically. At this

stage, the Mohs resection was complete.

 

 

 

_______________________________________________________________________________________________

 

Mohs Wound Disposition Report

 

Repair: Complex linear layered closure

Repair size:

Subcutaneous suture: 

Skin suture:

 

After the Mohs procedure was completed, the patient was brought back to the

minor surgery operatory. The patient was placed in a recumbent position and

the area was prepped and draped in the usual manner. Local anesthesia was

maintained with infiltration of additional 1% lidocaine with 1:100,000

epinephrine. Using curved iris scissors, the surgical defect was undermined

at the level of the subcutaneous tissue and the Mohs bevel was trimmed from

the wound edges. Hemostasis was maintained throughout the procedure using the

electrosurgical unit. Buried, inverted, interrupted sutures were used to

close the subcutaneous layer. Closure of the round Mohs defect resulted in

two redundant tissue cones. These were removed as Burow's triangles. The skin

edges were then approximated with a running suture. A pressure dressing

composed of petrolatum ointment, Telfa and sterile gauze was securely taped

into place. The patient was given complete verbal and written wound care

instructions and was asked to follow up PRN for a wound check. Also discussed

was the necessity of longitudinal follow up care with the referring

physician.  The patient was discharged in excellent condition.

 

 

Surgeon: Jayne Joo, MD

Resident:

Nurse(s):

Histology technician: Rachel Cortez

 

 

_______________________________________________________________________________________________

 

Mohs Wound Disposition Report: Second Intention Healing

 

The patient was brought back to the minor surgical operatory. The patient was

placed in a recumbent position and the area was prepped and draped in the usual

manner. The wound was allowed to heal by second intention. Local anesthesia was

obtained with infiltration of 1% lidocaine with 1:100,000 epinephrine. Gelfoam

and a sterile pressure dressing were applied. The patient was given complete

verbal and written wound care instructions and was asked to follow up PRN for a

wound check. Also discussed was the necessity of longitudinal follow up care

with the referring physician.  The patient was discharged in excellent

condition.

 

 

_______________________________________________________________________________________________

 

Mohs Wound Disposition Report

 

Repair: Full-thickness skin graft

Repair size:

Donor site:

Skin suture: 5-0 Vicryl Rapide and 5-0 Fast absorbing gut (graft recipient), 4-0

Vicryl and 5-0 Fast absorbing gut (graft donor site), 2-0 Silk (bolster

dressing)

 

The patient was brought back to the minor surgical operatory. The patient was

placed in a recumbent position and the area was prepped and draped in the

usual manner. Local anesthesia was obtained with infiltration of 1% lidocaine

with 1:100,000 epinephrine. Because a side-to-side repair would have caused

excessive distortion of the normal surface anatomy, a skin graft was selected

as the most appropriate reconstruction option. The donor site was prepped

and draped in the usual manner. An outline of the donor skin was drawn using

a sterile surgical marking pen. Anesthesia was obtained with local

infiltration of 1% buffered lidocaine with 1:100,000 epinephrine. The donor

skin was obtained by the appropriate method. Hemostasis at the donor site was

maintained using the electrosurgical unit.  Donor site was closed in standard

intermediate layered fashion with intradermal buried vertical mattress sutures

using 4-0 Vicryl and 5-0 Fast absorbing gut in simple running fashion.

 

The donor skin was then laid into the recipient site and trimmed to fit the

defect. The graft was sutured into place with 5-0 Vicryl rapide sutures simple

interrupted sutures and 5-0 Fast absorbing gut simple running sutures. A bolster

dressing composed of petrolatum ointment, cotton balls, and Xeroform were then

sewn in place with 2-0 Silk.  Vaseline and a dry sterile pressure dressing were

applied to the donor site and right hand.  The patient was given oral and

written wound care instructions.  He was instructed to keep the dressings clean

and dry until his follow-up in 1 week.

 

 

_______________________________________________________________________________________________

 

LASER (PDL) Procedure Note

 

Procedure Type: Cynosure Pulsed Dye LASER Treatment

Problems from previous Laser Tx: None

Treatment #: ***

Skin Type: ***

Tan present?: ***

Surgeon: ***

Assistant: ***

Treatment Location: ***  

Indication: ***

Preoperative diagnosis: Same as indication.

Postoperative diagnosis: Same as indication.   

Preoperative medications:  The patient was given an ice pack and asked to apply

it 10 minutes out of every 60 minutes for the rest of the day. ***      

Consent Explained to and Signed by Patient and Surgeon: yes       

Anesthesia: None 

Wavelengths: 585 nm

Spot Size: *** mm

Overlapping: None

Pulse Duration: *** msec PDL.

Fluence: *** J/cm2 PDL

Total Number of Pulses: ***

Total Passes: ***

Multiplex Pulse Delay: NA

Smart Cool Device Setting: 6 ***

Treatment Area: *** cm2

Complications: None

Discharge Medications: Ice pack 10 min out of 60 min. ***

 

Description of the procedure: The patient was brought to the outpatient

operatory and the procedure was described in detail.  The patient was explained

the risks of permanent pigmentation changes including hyper and

hypopigmentation, scar, infection, burn, pain, and failure to resolve condition,

and worsening of the condition.  The patient indicated verbally that they

understood and signed the consent form prior to procedure.  They appeared to

understand their risks.

 

The patient was positioned on the operating table and placed in a supine

position.  Laser precautions were utilized with all members in the room wearing

appropriate protective eye gear.  A laser precaution sign was placed on the

outside door.  Topical gel was applied to the patient's treatment area prior to

treatment.  After laser precautions were ascertained, treatment was begun at the

indicated areas above using the specified parameters. 

 

The Vascular LASER handout was given to the patient following the procedure.  I

explained to the patient that they need to protect the treatment area from sun

both before and after the procedure.  I also asked the patient to call the

number of on the instruction sheet should they have any concerns or

complications.  The patient tolerated the procedure well and ambulated to the

exit.  They were discharged in excellent condition.

 

 

_______________________________________________________________________________________________

 

Dermatology Clinic Note

 

CC:

 

DERMATOLOGIC HISTORY:

 

PMH:

|PROBLEM LIST ACTIVE|

 

ROS: denies f/c/n/v, cough, unintentional weight loss.

 

SOC HX: Does not smoke. Does not drink.

 

EXAM: Examination of the scalp, ears, face, neck, chest, back, abdomen, and

upper and lower extremities, including the nails and fingers were normal except

for the findings documented in the A/P.

 

LABS:

 

IMPRESSION/PLAN:

 

HPI:

PE:

ASSESSMENT:

PLAN:

 

RTC in

 

The patient was seen under the supervision of Dr. .

 

 

_______________________________________________________________________________________________

 

 

_______________________________________________________________________________________________

 

 

_______________________________________________________________________________________________

 

 

_______________________________________________________________________________________________

 

 

_______________________________________________________________________________________________