Dermatology Clinic Case Summary
REASON
CHIEF COMPLAINT: Followup.
HISTORY
This is a followup dermatology clinic visit. See Dr. Tara Stewart's dermatology consult from 05/13/2016. The patient has posterior hip herpetic neuralgia over his right neck continues to be troublesome for him. He says his other issues that were discussed in May are much improved. These consisted of apparently some scales and scaly macules and patches over his chest, arms, shoulders, neck, and ears that had some crusting. This he says is all improved and doing well. He is currently followed in the Pain Clinic for his post herpetic neuralgia. His cutaneous issues improved about one month after the dermatology clinic visit in 05/2016. He is now concerned about residual pain in his right scalp and neck and one itchy site on his right thigh that comes …show more content…
He is generally clear of seborrheic dermatitis or tinea versicolor except a faint scaly patch over his right anterior axillary fold and over his left posterior auricular fold. He has one 5-6 x 2.5-3 cm mildly psoriasiform low plaque over his right anterior proximal thigh.
ASSESSMENT AND PLAN
1. Post herpetic neuralgia. Suggest continuing pain management clinic as currently planned.
2. Probable seborrheic dermatitis versus atypical tinea versicolor which is minimal today. Suggest using ketoconazole 2% shampoo as if he had tinea versicolor. To use this he should lather his head, neck, ears, trunk and arms and leave the lather on for five minutes and rinse off for three days in a row and then repeat this every three months for at least one year. He should continue using his Head and Shoulders shampoo daily, otherwise.
3. Psoriasiform dermatitis versus localized psoriasis right thigh. Suggest resuming triamcinolone 110% cream t.i.d. to his right thigh until clear and then p.r.n.
4. Return to the dermatology clinic in three
CHIEF COMPLAINT: Followup.
HISTORY
This is a followup dermatology clinic visit. See Dr. Tara Stewart's dermatology consult from 05/13/2016. The patient has posterior hip herpetic neuralgia over his right neck continues to be troublesome for him. He says his other issues that were discussed in May are much improved. These consisted of apparently some scales and scaly macules and patches over his chest, arms, shoulders, neck, and ears that had some crusting. This he says is all improved and doing well. He is currently followed in the Pain Clinic for his post herpetic neuralgia. His cutaneous issues improved about one month after the dermatology clinic visit in 05/2016. He is now concerned about residual pain in his right scalp and neck and one itchy site on his right thigh that comes …show more content…
He is generally clear of seborrheic dermatitis or tinea versicolor except a faint scaly patch over his right anterior axillary fold and over his left posterior auricular fold. He has one 5-6 x 2.5-3 cm mildly psoriasiform low plaque over his right anterior proximal thigh.
ASSESSMENT AND PLAN
1. Post herpetic neuralgia. Suggest continuing pain management clinic as currently planned.
2. Probable seborrheic dermatitis versus atypical tinea versicolor which is minimal today. Suggest using ketoconazole 2% shampoo as if he had tinea versicolor. To use this he should lather his head, neck, ears, trunk and arms and leave the lather on for five minutes and rinse off for three days in a row and then repeat this every three months for at least one year. He should continue using his Head and Shoulders shampoo daily, otherwise.
3. Psoriasiform dermatitis versus localized psoriasis right thigh. Suggest resuming triamcinolone 110% cream t.i.d. to his right thigh until clear and then p.r.n.
4. Return to the dermatology clinic in three