Dermatology Chart Note 1 Yanktonai, Lakota
May 2, 2015
Patient is a 9 year old adolescent male, presents with a 2 day history of itching encrusted sores especially around the mouth area. Parent is using OTC antibiotic ointment with no improvement, no recent history of fever. Parent states that pat recently visited a petting zoo
HEENT are basically unrevealing. Temp in the office today is 98.4. The outer area of the mouth extending into the chin reveals macules, vesicles, copious purulent exudate forming honey- colored crust on a erythematous base. Skin on trunk, arms and legs is clear. No other symptomology
1. Rx for Mupirocin ointment applied to infected area TID.
2. Advised…show more content…
She has been sleeping better and her appetite has improved. She believes the outpatient therapy session have helped her with coping mechanisms. She has been trying to use diaphragmatic breathing techniques to assist her with her anxiety symptoms
Vitals Temp: 98.6 P: 83 Res: 18 BP: 126/70
General alert and compliant
Effect has improved display of a variety emotional expressions
APPEARANCE hygiene appears to be good. No detection of a skin lesions or rash
HEART regular rate and rhythm
Generalized anxiety disorder with mild depression.
Continue Lexapro at 5 mg a dose and Klonopin at 3mg a dose. Continue outpatient counselling. Patient will follow up in 2 weeks or earlier if anxiety symptoms worsen.
Milton E. Eisenberg, MD
Akhtar, Renita M.
May 4, 2015
This patient has been referred to me by her primary care physician. Patient states she has been suffering from irritability. She states that she has been very irritable for short periods of time. She associates these feelings with her depression.
HISTORY PRESENT ILLNESS
The patient is a 56 year old female who has recently lost her job and has been financially struggling. She has isolated herself from friends and family members. She claims to be close to her older sister but