DERMATOLOGICAL SAMPLE WRITE-UP
Below is a sample write-up of a patient without any significant physical exam findings. Please pretend as though you saw one of disease cases from the handout given in class & replace the physical exam findings below with those listed in the case. If no information was given in the case, assume a normal finding (i.e. such as a finding from your lab partner).
Provider Name: Bugs Bunny, M2, 333-ACME
Date: Physical exam on 2 January 2010, 10:15 am
Patient ID: Patient Name, age, date-of-birth, profession
CC: chief complaint and duration
Temp:98 °F Pulse: 60, regular rate and rhythm
Resp: 12 BP: 125/75 (sitting, right arm)
Pain: 0/10 2nd BP: 148/84 (seated, right arm)
Height: 5’ 3” (by pt. report)
Weight: 132# (by pt. report)
BMI: please calculate(kg/m2)
Skin, Nails, & Hair
Color pink. Skin warm and moist. No rash, petechiae, or ecchymosis. No suspicious nevi [Use A,B,C,D criteria. If suspicious nevi present, include size, color, and recent changes]. Nails without clubbing or cyanosis. No sign of onychomycosis in hands or tocnails. Hair distribution is full, with no signs of seborrheic dermatitis or alopecia.
[illustration as appropriate]
Please include your suspected diagnosis for the cases given in the class handout, as well as a brief (1 – 3 sentences) justification for your diagnosis. (1 pt)
STOP HERE. DO NOT INCLUDE CARDIOPULMONARY EXAM.
Synched 1-10 with “3)Derm_PE_1-1-09” and Bates 10th ed pg 170