Describing A Dermatologic Condition Report Examples

A 25 year old female presents herself to a dermatologic clinic complaining of persistent rashes on her upper back and legs. Severe pruritus (itching) is also present. In addition, the patient also complains of diaphoresis (Excessive sweating) at night. She claims that these symptoms have been prevalent for the past 4 weeks and have been progressively becoming worse. The patient had tried using over-the counter antifungal lotion (Ammonium lactate) and Lamisil cream. The medical history of this patient includes instances of facial acne which she usually controls through regular demabrasion, and also has a history of pediculosis during her childhood days which was however successfully treated by completely shaving of the head. It is also worth noting that the patient’s surgical history includes a pilonidal abscess which was treated through incision and drainage.
In regard to her family’s medical history, her father suffers of seborrheic keratosis which is however routinely treated with cryotherapy. There is a long –standing history of diabetes history in her mother which ultimately resulted into peripheral neurophathy and a below knee amputation which was caused by a non-healing ulcer. Multiple sclerosis in her maternal grandmother resulted in a decubitus ulcer which is secondary to immobility. Currently, the patient’s medication includes multivitamin, Ortho-Tricycline and Loratadine. Upon examination, it can be noted that the patient is in moderate distress. There is a widespread erythematous macule-papular rash which largely involves the epidermal layer on her lower extremities and her upper back. There also includes areas of around 3cm wheals on the upper part of her back as well. There is no evidence of Petechia, ecchymosis or lymph node enlargement.
ASSESMENT: Perform a shave biopsy of the area where rashes persist. Continue the use of anti-histamine (Loratadine). Stop the use of Keratolytic. Prescribe the use of Triamcinolone cream twice daily, and also follow up on the results of the biopsy.