Download 皮膚科標準病歷範本

皮膚科標準病歷範本
一. 【Contact dermatitis】
--Chief complaint: Skin rash over hands for 6 years.
--Present illness:
A 28-year-old man with a 6-year history of a chronic rash on his hands came to us. He had
been working as a baker for almost ten years and has had a rash since he was an apprentice.
However, he hadn’t been too concerned about it until recent years when it became worse.
However, he had not sought medical advice. He stated that his hands were erythematous,
swollen, dried, and fissured. The symptoms were partially relieved on holidays or when he
was off from work. He worked with various materials, including flour, flavoring agents,
enzymes, butter, dairy products, eggs, meat, fruits, and vegetables. Particularly after handling
cucumber, bacon, and eggs, he noted the development of immediate, pruritic, and stinging
vesicular eruption. Ingestion of these foods, however, did not cause any reaction. He held the
offending food with his left more often than with his right hand.
Physical examination revealed fissures, desquamation, lichenified, and hyperkeratosis on
an erythematous base on the palms, fingers, and dorsum of both hands. The nail fold was
swollen and the cuticle was absent. These findings were most prominent on the volar aspects
of fingers, followed by the palms, and then the backs of the hands. The left hand was more
severely affected than the right.
--Impression: Contact dermatitis, suspect protein related
--Plans: Further survey for the source of contact dermatitis, and avoid exposure
二.【Diagnosis:
1.Herpes zoster, left S2 area with urinary retention. 2 End stage renal
disease status post renal transplantation】
--Chief complaint: Skin lesions over ingunal area and anus for 6 days
--Present illness:
The 44-year-old woman with history of ESRD had had renal transplantation in China in 2007;
she received regular immunosuppressive treatment at our hospital. One week prior to
admission, she experienced mild neuralgia in her inguinal area first. Multiple grouped vesicles
were noted on the next day, and she also had mild difficulty urinating. In the following few
days, the number of vesicles increased and they spread to her anus. She came to our OPD for
help, and herpes zoster with involvement of S2 dermatome was impressed. Due to the past
history of renal transplantation and difficulty of urination, she was admitted for further
management.
--Impression: Herpes zoster, left S2 area with urinary retention
--Plans: 1) On Foley
2) Acyclovir 500mg Q12H IV drip
3) Neurologic pain control
4) Wound care
三.【Wegener’s granulomatosis】
--Chief complaint: Painful facial lesion over bilateral cheek for 2 weeks.
--Present illness:
A 31-year-old man presented with painful facial ulcers on the bilateral cheeks and
forehead of 2-week duration. History of recent contact included superficial chemical peeling
with glycolic acid and squeezing his cystic acne. The ulcers were shallow, clean and had a
relatively broad base, with particular lesions over the left face arranged in a bizarre linear
pattern. Self-induced pyoderma was suspected. However, the ulcers did not improve with
antibiotic treatment. One month later, the patient was admitted under the impression of
pulmonary tuberculosis and meningitis because of fever, cough, yellowish sputum, headache
and nuchal rigidity lasting for 3 weeks.
Lab studies revealed significant leukocytosis (19.2 × 109/L), elevated C-reactive
protein levels (149.83 mg/L [1427 nmol/L]), elevated liver functions (GOT, 94 IU/L; GPT,
121 IU/L), elevated ESR (43 mm/hr), pyuria, and microscopic hematuria. X-ray and
computed tomography revealed multisinus sinusitis and lung cavitations over both apices of
the lung.
--Impression: 1) Suspect self-induced pyoderma, bilateral cheeks
2) Suspect pulmonary tuberculosis
3) Suspect meninigitis
4) Suspect autoimmune disease
--Plan: 1) Sputum culture
2) Arrange further autoimmune profile (C-ANCA, P-ANCA, RA factor)
四.【 Dissecting cellulitis, bilateral cheeks and nape】
--Chief complaint: Painful nodules over bilateral necks for 2 weeks.
--Present illness:
The 16 y/o boy had no hisory of any systemic disease or congenital anomaly. He has had
recurrent painful carbuncles and furnucles on face, scalp or bilateral neck since 2007. Two
painful erythematous nodules (about 5*5cm in size) on bilateral neck and several
erythematous papules on face were noted 2 weeks ago. He came to our Derma OPD for help
on 2010/07/14; I&D was performed yielding 10cc of pus. There was fever noted during this 2
weeks. He also denied having shortness of breath, stridor or any discomfort despite neck pain.
Lab studies revealed leukocytosis with segment predominent (WBC 16400, Seg 74.3%) and
elevated CRP (16.3). ENT was consulted to rule out deep neck infection, and intact vocal cord
and pharynx without swelling was noted. Under the impression of bilateral neck carbuncle, he
was admitted for further management.
--Impression: Dissecting cellulitis, bilateral cheeks and nape
--Plan: 1) Minocycline iv use
2) Apply for the use of Roaccutane
五. 1) 【Bacteremia, left leg cellulitis and right hand abscess related】
2) 【Generalized eczema】
--Chief compliant: Generalized itchy skin lesions progressed for 2-3 days.
--Present illness:
The 86-year-old man has history of (1)senile dementia, (2)coronary artery disease, three
vessels disease s/p coronary artery bypass graft, (3)hypertension, (4)chronic obstructive
pulmonary disease under medical treatment, (5) hyperlipidemia and (6) chronic kidney
disease.
According to his wife's statement, multiple itchy skin rash, off and on, on bilateral extremities
and back have been noted more than one year ago. He was hospitalized due to generalized
eczema with secondary infection from 2010/06/14 to 2010/06/21. The skin lesions subsided
after discharge. However, multiple erythematous, itchy plaques with excoriation on bilateral
extremities and back have progressed in these 2-3 days. In reviewing his history, he did not
take any new drugs or eat any special food in the past one month. Under the impression of
severe generalized eczema, he was admitted for further evaluation and management.
--Impression: 1) Cellulitis, left leg. 2) Abscess, right hand. 23) Generalized eczema.
--Plan: 1) Intravenous antibiotics use
2) Topical steroid for generalized eczema
3) Phototherapy with narrow band UVB
六.【 Hailey-Hailey disease with secondary infection and chronic ulcers】
--Chief complaint: Painful skin lesions over bilateral axillary and inguinal area
--Present illness:
The 50-year-old man has history of hyertension and Hailey-Hailey disease for more than 20
years. The initial presentation was eczema-like skin lesions in the inguinal and axillary area.
He went to many LMD for help but the symptoms persisted. He had biopsy at NCKH and was
diagnosed of Hailey-Hailey disease. Then, he was on regular follow up at our hospital. In
reviewing his family history, none of the family members has ever had the same skin lesions.
This time, he came to our OPD due to progressive painful and ulcerative skin lesions. Large
areas of erythematous, hypertrophic, and ulcerative patches with pus discharge and rhagades
in bilateral axillary and inguinal area were noted. The wound culture obtained on 2010/08/18
showed Morganella morganii and Enterococcus species. No fever or other systemic symptoms
were noted. Under the impression of deteriorated Hailey-Hailey disease with superimposed
bacterial infection, he was admitted for further evaluation and management.
--Impression: Hailey-Hailey disease with secondary infection and chronic ulcers
--Plan: 1) Intravenous antibiotics use
2) Phototherapy with 660nm low energy laser on ulcers
七.【 Bullous drug eruption】
--Chief complaint: Multiple bullae over four limbs and left anterior chest for 2 days.
--Present illness:
This 34-year-old man has no history of any systemic disease. He collects recycle materials for
a living. According to the patient's statement, multiple bullae over four limbs and his left
anterior chest wall were noted for 2 days. Skin itching over the whole body was also
complained. He had visited our ER on 99-07-31, where he was treated with Vena,
prednisolone and Keflex. However, his symptoms progressed with new bullae formation after
discharge. Thus, he came to our OPD on 99-08-02 where a skin biopsy was performed. In
reviewing his history, he took some unknown analgesics about one week ago, and the skin
lesions appeared after the medication. His hemogram showed W.B.C.[11.6 10^3/uL]，
R.B.C.[4.86 10^6/uL]，Hb[16.4 g/dL]. There was no fever, no dizziness, no chest pain. Under
the impression of bullous drug eruption r/o bullous pemphigoid, he was admitted for further
evaluation and management.
--Impression: Suspect bullous drug eruption, r/o bullous pemphigoid
--Plans: 1) Perform skin biopsy
2) Solumedrol use
3) Wound care
八.【 Disseminated Candidiasis】
--Chief complaint: Persisted fever and skin lesions for 10 days.
--Present illness:
A 29-year-old woman with acute myeloid leukemia developed pancytopenia and fever
10 days after the second course of consolidation chemotherapy with cytarabine and idarubicin.
Her full blood count revealed white cell count of 80/uL (normal 4500-10000), hemoglobin of
9.1 g/dl (normal 11.3-15.3), and platelet count of 2000/uL (normal 150000-400000).
Piperacillin/tazcobactum and amikacin sulfate were prescribed, yet fever persisted. One week
after fever started, generalized skin rashes and myalgia developed. Skin examination revealed
multiple erythematous rash, 3-5 mm maculopapules with purpuric centers over face, trunk and
limbs without symptoms. An incisional biopsy was taken from the abdomen for routine H&E
stain and periodic acid-Schiff staining. Three sets of blood cultures grew Candida tropicalis.
Under the impression of disseminated candidiasis, she was admitted for further management.
--Impression: Disseminated Candidiasis
--Plans: Antifungal agents with 50mg intravenous caspofungin acetate was administered daily
and oral voriconazole 200mg was taken twice daily.
九.【 Herpes zoster with secondary bacterial infection, right T9-10 area】
--Chief complaint: Painful skin lesions over abdomen and back were noted for over 10 days.
--Present illness:
The 69 y/o woman has history of 1) HTN and 2) COPD under regular medication. This time,
several vesicles have been noted on her right abdomen and back since 10 days ago. She used
some unknown medications offered by her neighbor. There was no fever noted. She came to
our Derma OPD on 2010/06/29, and several erythematous plaques surrounded by serum crust
were noted. However, increased amount of vesicles with erythematous change and serous
discharge were noted. She also complained about severe pain. Thus, she came to our ER on
07/01. The wound culture showed Pseudomonas and Enterobacter infection. Under the
impression of herpes zoster with secondary infection, she was admitted for further evaluation
and management.
--Impression: Herpes zoster with secondary bacterial infection, right T9-10 area
--Plans: 1) Intravenosu antibiotics use. 2) Wound care.
十. 【Naproxen-induced pseudolymphoma syndrome】
--Chief complaint: Fever and itchy skin rashes over the whole body for 3 days.
--Present illness:
This is a 65-year-old man with benign prostate hyperplasia and diabetes mellitus type 2
receiving regular medical attention (tamsulosin HCl, tolterodine for benign prostate
hyperplasia, acarbose, glimepiride for diabetes mellitus for more than 1 year) at a tertiary
medical center in Central Taiwan. Due to an episode of fever, nausea, vomiting and persistent
epigastralgia, he was admitted to the hospital, where Empiric antibiotics with intravenous
cefazolin and gentamicin, medication for benign prostate hyperplasia and diabetes mellitus, as
well as acetaminophen and metoclopramide were prescribed. During hospitalization,
abdominal computed tomography with contrast enhancement showed pancreatic cancer and
surgical excision was recommended. But the patient was discharged against medical advice.
After discharge, he took naproxen, levofloxacin and drugs for benign prostate
hyperplasia and diabetes mellitus prescribed at discharge. Three days later, he had a fever (up
to 39°C) and itchy skin rashes all over the body except the palms and soles. Physical
examination revealed pruitic and confluent maculopapular eruption on the trunk and all four
limbs, but no enlarged lymph nodes. Laboratory investigations revealed leukocytosis (13.9 ˜
109/L), eosinophilia (1.0 ˜ 109/L), and atypical lymphocytes (0.3 ˜ 109/L). Liver function
tests showed a mildly elevated aspartate aminotransferase level (1.0 μkat/L) and increased
alkaline phosphatase (3.9 μkat/L). Under the impression of drug eruption, he was admitted
for further evaluation and management.
--Impression: Drug eruption, suspect naproxen related
--Plan: 1) Performed skin biopsy.
2) Stop naproxen use.
3) Fever work-up.