Sample Name: Acne - SOAP
Description: Acne with folliculitis.
(Medical Transcription Sample Report)
SUBJECTIVE: The patient is a 49-year-old white female, established patient to Dermatology, last seen in the office on 08/10/2004. She comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest, stomach, neck, and back. On examination, this is a flaring of her acne with small folliculitis lesions. The patient has been taking amoxicillin 500 mg b.i.d. and using Tazorac cream 0.1, and her face is doing well, but she has been out of her medicine now for three days also. She has also been getting photofacials at Healing Waters and was wondering about what we could offer as far as cosmetic procedures and skin care products, etc. The patient is married. She is a secretary.
FAMILY, SOCIAL, AND ALLERGY HISTORY: She has hay fever, eczema, sinus, and hives. She has no melanoma or skin cancers or psoriasis. Her mother had oral cancer. The patient is a nonsmoker. No blood tests. Had some sunburn in the past. She is on benzoyl peroxide and Daypro.
CURRENT MEDICATIONS: Lexapro, Effexor, Ditropan, aspirin, vitamins.
PHYSICAL EXAMINATION: The patient is well developed, appears stated age. Overall health is good. She has a couple of acne lesions, one on her face and neck but there are a lot of small folliculitis-like lesions on her abdomen, chest, and back.
IMPRESSION: Acne with folliculitis.
1. Discussed condition and treatment with the patient.
2. Continue the amoxicillin 500 mg two at bedtime.
3. Add Septra DS every morning with extra water.
4. Continue the Tazorac cream 0.1; it is okay to use on back and chest also.
5. Referred to ABC clinic for an aesthetic consult. Return in two months for followup evaluation of her acne.
Keywords: dermatology, acne with folliculitis, tazorac cream, acne, tazorac, cream, folliculitis,