SUBJECTIVE: The patient has had a biopsy from her left nose, which showed actinic keratosis. The lesion, however, continues to recur. She was being treated with liquid nitrogen in the past. She has also noted a rough area below her left lower lip.

OBJECTIVE: She has a small rough scaly macule on the left side of the nose and other on the left lower lip. The area on the nose is just above the biopsy site.

ASSESSMENT: Actinic keratosis.

PLAN:
1. Recommended to treat with light Efudex cream twice daily for 3 weeks on both lesions.
2. Asked to call me if lesion recurs.
3. She was warned about hypopigmentation.

Sample #2

SUBJECTIVE: The patient is an (XX)-year-old woman who comes for followup of basal cell carcinoma to left thigh treated in January (XXXX). She has noted a rough area on the left nose but no other skin, hair, nail complaints. She did have a small stroke in July from which she has recovered.

OBJECTIVE: Full exam done. She has a well-healed scar on the left thigh. Her skin is clear. No lesions appreciated with the exception of a rough scaly papule on the left nose. She has scattered seborrheic keratosis also.

ASSESSMENT:
1. Actinic keratosis, left nose. This is treated with liquid nitrogen spray.
2. History of basal cell carcinoma left thigh, January (XXXX).

PLAN:
1. She will return in one year’s time.
2. Lesion will be also treated with cryosurgery.

Sample #3

This is a (XX)-year-old gentleman with a history of squamous cell carcinoma on his lip a year ago who returns for a skin exam. No lesions on his skin he is concerned about. He denies itching, pain or bleeding at any skin lesion.

MEDICATIONS: Atenolol, lisinopril, and hydrochlorothiazide.

ALLERGIES: NONE KNOWN.

Review of systems, social history, family history is being updated per the patient information sheet placed in his medical record.

OBJECTIVE: On examination of the face, neck, chest, abdomen, back, upper and lower extremities, hands and feet bilaterally, there are rough keratotic 2-4 mm macules on both cheeks in 4 locations altogether. The rest of the skin exam is unremarkable.

ASSESSMENT: Actinic keratoses.

PLAN: Liquid nitrogen, 10 seconds, for destruction of actinic keratoses. Continue sun screen. She is to followup in 1 year.

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SUBJECTIVE: The patient is a (XX)-year-old woman who returns for followup of rosacea and because of history of lichenoid keratosis. The patient reports that once every couple of months, the rosacea flares. She then started to use Noritate cream and sodium sulfacetamide, and within a month, she reports it has calmed down. The patient does not use the medications on a regular basis. Moderate sun exposure. She does use sunscreen for outdoor activities.

OBJECTIVE: The patient is alert and oriented x3. On examination of her face, neck, chest, abdomen, back, upper and lower extremities, hands, feet bilaterally, there are no worrisome pigmented lesions or other lesions worrisome for cutaneous malignancy. Face shows mild erythema on the forehead and cheeks.

ASSESSMENT: Mild rosacea, history of actinic keratosis.

PLAN: We discussed with the patient that she will see fewer flares of the rosacea if she uses the metronidazole 0.75% cream daily. The patient can increase to b.i.d. if it does flare. She can continue with the sodium sulfacetamide daily on a p.r.n. basis. Follow up in one year.

Dermatology SOAP Note Example 2

SUBJECTIVE: The patient is a (XX)-year-old woman who returns four weeks after beginning narrow-band UVB for chronic eczema. The patient’s eczema worsened significantly as she was tapering prednisone. She is now back to 20 mg prednisone daily; it had been tapered down to 7.5 mg. The patient is using clobetasol ointment on her skin. She does note that the itchiness has lessened, but she does not think the eczema has improved since she started phototherapy. She is presently on prednisone 20 mg daily, clobetasol ointment daily, hydroxyzine 10 mg q. 6 hours, betamethasone valerate lotion to the scalp, and desonide cream to the face p.r.n.

OBJECTIVE: The patient is alert and oriented x3. There are erythematous, slightly lichenified coalescing papules on the upper mid back, abdomen, proximal thighs, and arms. Face is clear.

ASSESSMENT: Chronic eczema.

PLAN: The patient will continue with the narrow-band UVB for an additional four weeks. We discussed with the patient if at that point she really has not had any improvement in her eczema, then it is unlikely that continuing phototherapy is going to be beneficial. We discussed with her again today that the phototherapy is not curative, but can have an additive benefit through other medications in managing the eczema. The patient voiced understanding of this, and she will continue with the narrow-band UVB three times weekly. Followup will be in four weeks.

Dermatology SOAP Note Example 3

SUBJECTIVE: The patient is a (XX)-year-old gentleman who returns for skin examination because of a history of basal cell carcinoma. He questions raised moles on his back, chest, legs; all of these are asymptomatic.

OBJECTIVE: The patient is alert and oriented x3. On examination of his face, neck, chest, abdomen, back, upper and lower extremities, hands, feet bilaterally, he has sebaceous hypertrophy diffusely on the dorsal and distal aspect of the nose. There are no inflammatory papules or pustules seen. There are multiple tan brown and gray stuck-on keratotic papules and plaques widely scattered on the back, chest, and legs; none with worrisome features.

ASSESSMENT: Multiple seborrheic keratoses. No sign of new basal cell carcinoma, rosacea with rhinophyma changes.

PLAN:
1. The patient wants to try stopping the tetracycline. We discussed with him the rosacea may have remitted. On the other hand, we discussed with him if he does start developing new areas of redness, pustules on the nose, would recommend resuming the tetracycline 500 mg p.o. b.i.d. He voiced understanding of this. He was given a written prescription, so can restart the medication if needed.
2. Reassurance regarding all of the other skin lesions he questions. Follow up again in one year because of a basal cell carcinoma.

Dermatology SOAP Note Example 4

SUBJECTIVE: The patient is a (XX)-year-old woman who returns for followup of hand eczema. She is very pleased with the improvement in her skin and has no other complaints regarding her skin today.

OBJECTIVE: The patient is alert and oriented x3. Palmar surface of right, greater than left hand, shows mildly erythematous, dry patches and similar changes on the dorsal surface of several of the fingers.

ASSESSMENT: Atopic eczema with component of chronic irritant contact dermatitis, improved.

PLAN:
1. Encouraged her to continue and increase moisturizer as her skin is still quite dry.
2. Continue with the mometasone ointment b.i.d. to the eczematous areas.
3. We discussed with her if it becomes severe, she can resume the clobetasol ointment, but not for longer than two weeks continuously. Followup is p.r.n.

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SUBJECTIVE: The patient comes in today with a slightly tender spot on the left helix of the ear. He notes that it is sore a little bit at night when he sleeps on it, but not appreciably so. He noted it first at the end of March and just wants to make sure it is harmless and not a cancer. Other than it being tender, he has no other symptoms related to this, and he has not treated it in any way.

OBJECTIVE: Well appearing, normal respiratory effort, oriented, normal affect and mood. Exam included his left ear.

ASSESSMENT AND PLAN: Rule out chondrodermatitis nodularis helicis versus actinic keratosis. On the left helix, he had a crusty scaly patch that was about 2 mm in diameter, and the lesion was numbed with lidocaine/epinephrine and a shave biopsy was done to rule out actinic keratosis. If it is negative for actinic keratosis, we discussed with him that he can simply leave it, or if he becomes too symptomatic, we certainly could try to inject it with Kenalog.

We will see him back in Dermatology on an as-needed basis.

Dermatology SOAP Note Sample #2

SUBJECTIVE: The patient is a (XX)-year-old gentleman who comes in today for a skin check and also psoriasis check. He had psoriasis on the last visit, on his right palm, and he also notes a spot on his right thumb that he tends to pick at and is always a little bit fissured, but he is not using any medication on this. The last time I saw him, he noted it did not bother him, so although he had some triamcinolone at home, he was not using it. He notes today that his lower legs itch and, in particular, the normal skin on lower leg itches rather than a red, rashy skin that I see today. He also notes he has multiple brown spots on his trunk and wants me to check them.

OBJECTIVE: Well appearing, normal respiratory effort, oriented, normal affect and mood. Exam included the scalp, face, eyelids and conjunctivae, lips, neck, chest, abdomen, back, buttocks, right and left upper and lower extremity.

ASSESSMENT AND PLAN:
1. Psoriasis: He had three pink scaly patches on his lower legs consistent with psoriasis, and I am going to give him Lidex ointment to apply twice a day to these patches. Also, on his hand, he had some hyperkeratosis of the palm as well as fissuring on his right thumb and this is also consistent with psoriasis. I am going to have him use the Lidex there as well.
2. Itchy legs and dry skin: On his lower legs, he had some dry skin in addition to the patches of psoriasis. I discussed he can use Sarna lotion as needed and Cetaphil or Eucerin moisturizing lotion there as well.
3. Seborrheic keratosis: On his trunk, he had multiple brown plaques consistent with benign seborrheic keratoses. No treatment needs to be done.

We will see him back in six months in Dermatology to check his psoriasis.

Dermatology SOAP Note Sample #3

SUBJECTIVE: The patient is a (XX)-year-old woman who comes in today for a skin check. Her last one was on MM/DD/YY. She has had a basal cell skin cancer on left chest on MM/DD/YY and then, in YYYY, she had a squamous cell carcinoma in situ on her nose. She has no new or changing lesions she is concerned about today. She is battling stomach cancer and is in remission currently. She has had metastasis to the lungs with resection of that in the past.

OBJECTIVE: Well appearing, normal respiratory effort, oriented, normal affect and mood. Exam included the scalp, face, eyelids and conjunctivae, lips, neck, chest, abdomen, back, buttocks, right and left upper and lower extremity.

ASSESSMENT AND PLAN:
1. History of basal cell skin cancer and squamous cell carcinoma in situ on her left chest and left nose: She had no evidence of recurrence in the scar site of each of these areas.
2. Nevi: She had a few brown macules and papules scattered on torso and extremities with none concerning for malignancy.

We will see her back in Dermatology in a year.

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ABCD (asymmetry, border, color, and diameter)

Accutane

acne

acne vulgaris

actinic keratosis

albino

allergic contact dermatitis

allergic eczema

alopecia

angioedema

angular cheilitis

angular stomatitis

anhidrosis

anicteric

aphthous stomatitis

atopic dermatitis

atypical skin lesions

basal cell carcinoma

Behcet disease

benign-appearing nevi

bulla

bullae

callus

chancre

collagen

comedo

comedones

condyloma

condylomata

cyst

decubitus ulcer

dermatologist

dermatomycosis

dermatoplasty

dermis

diaper dermatitis

diaper rash

diaphoresis

ecchymoses

ecchymosis

eczema

electrodesiccation

epidermis

epithelium

erythematous

erythematous, scaly rash

exanthema

exanthematous

excoriation

fleshy mole

folliculitis

freckle

hidradenitis

hidradenitis suppurativa

Hutchinson freckle

hyperkeratosis

hyperpigmentation

ichthyosis

impetigo

integumentary

intertriginous

intertrigo

itchiness

Kaposi sarcoma

keloid

keratin

keratosis

leishmaniasis

lentigines

lentiginous junctional dysplastic nevus

lentigo

leukoderma

leukoplakia

lichenification

Lidex cream

lipoma

macule

maculopapule

malar erythema

melanin

melanocyte

melanoma

Mohs surgery

mole

mottled hyperpigmentation

nevi

nevus

onychomycosis

papule

paronychia

petechia

petechiae

photoaging

photodamaged skin

pilonidal cyst

pityriasis rosea

poison ivy

polyp

prickly heat

proliferative dermatitis

pruritic rash

pruritus

pruritus ani

psoriasis

psoriatic

psoriatic plaques

purpura

purulent

pustule

pyoderma

Retin-A

Rhus dermatitis

rosacea

rubella

rubeola

scabies

scleroderma

sebaceous gland

seborrheic blepharitis

seborrheic dermatitis

sebum

skin tag or skin tags

slow Mohs (surgery or procedure)

solar dermatitis

Spectazole cream

squamous cell carcinoma

squamous epithelium

steatoma

stomatitis

stork bites

strawberry hemangiomas

sty

subcutaneous

subungual

sun-damaged skin

systemic lupus erythematosus

tan lines

tinea cruris

tinea versicolor

triamcinolone cream

turgor

ulcer

urticaria

verruca

verrucae

vesicle

vitiligo

wart

weeping eczema

wheal

wheal-and-flare reaction

whitehead

xanthoma

xeroderma

xerosis

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