Itch

Patient presents with pruritus, also known as itching.  The onset of itch was [duration] and is described as [quality of itch: burning, tingling, prickling, etc.].  The location of the itch is [body area affected: localized, generalized] and the severity is [mild, moderate, severe] impacting sleep and daily activities.  Associated symptoms include [list any associated symptoms: rash, skin lesions, dryness, redness, swelling, pain, fever, fatigue, weight loss, etc.].  Patient denies any known allergies, recent travel, or exposure to new irritants.  Medical history includes [list relevant medical history: atopic dermatitis, eczema, psoriasis, diabetes, liver disease, kidney disease, thyroid disease, HIV, cancer, etc.].  Medications include [list current medications].  Physical examination reveals [describe skin findings: erythema, excoriations, lichenification, dryness, scaling, lesions, etc.].  Differential diagnosis includes xerosis, contact dermatitis, atopic dermatitis, urticaria, scabies, drug eruption, and systemic causes such as cholestasis, chronic kidney disease, and Hodgkin lymphoma.  Assessment:  Pruritus, likely secondary to [presumptive diagnosis].  Plan:  Patient education provided on avoiding scratching and maintaining skin hydration.  Prescribed [treatment: topical corticosteroids, antihistamines, emollients, etc.].  Follow-up scheduled in [duration] to assess response to treatment.  ICD-10 code:  [appropriate ICD-10 code based on presumptive diagnosis. For example, L29.9 - Pruritus, unspecified].  Referral to [specialist, if necessary: dermatologist, allergist, etc.] may be considered if symptoms persist or worsen.