www.Online-Medical-Transcription-Course.com

DERMATOLOGY CONSULTATION

HISTORY: Mr. Smith came here complaining of itchy legs, which have been scratched by a cat for the last 3 months. He states that he has been using peroxide but it is not clearing up. He is a known diabetic. 

PHYSICAL EXAMINATION: He is a heavyset gentleman. Lower legs have widespread scratch marks. The skin is very dry. 

DIAGNOSIS: Scratch marks with secondary infection. 

PLAN: I advised him to stop everything topical and use only bacitracin ointment two times a day and follow up in one week.