Dermatitis – SOAP
SUBJECTIVE: This is a 29-year-old Vietnamese female, established patient of dermatology, last seen in our office on 07/13/04. She comes in today as a referral from ABC, D.O. for a reevaluation of her hand eczema. I have treated her with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion, and wash her hands in Cetaphil cleansing lotion. She comes in today for reevaluation because she is flaring. Her hands are very dry, they are cracked, she has been washing with soap. She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin. She has been wearing some gloves also apparently. The patient is single. She is unemployed.
FAMILY, SOCIAL, AND ALLERGY HISTORY: The patient has asthma, sinus, hives, and history of psoriasis. No known drug allergies.
MEDICATIONS: The patient is a nonsmoker. No bad sunburns or blood pressure problems in the past.
CURRENT MEDICATIONS: Claritin and Zyrtec p.r.n.
PHYSICAL EXAMINATION: The patient has very dry, cracked hands bilaterally.
IMPRESSION: Hand dermatitis.
1. Discussed further treatment with the patient and her interpreter.
2. Apply Aristocort ointment 0.1% and equal part of Polysporin ointment t.i.d. and p.r.n. itch.
3. Discontinue hot soapy water and wash her hands with Cetaphil cleansing lotion.
4. Keflex 500 mg b.i.d. times two weeks with one refill. Return in one month if not better; otherwise, on a p.r.n. basis and send Dr. XYZ a letter on this office visit.