Podiatry Documentation (Skin Inflammation - Tissue Sampling) Template

Patient: John Doe  
Account No: 123456  
Date: 1 November 2024  
Subjective:  
This 45-year-old patient visits the office today with a recurring dermatitis flare-up. The patient reports itchiness and inflammation affecting the right lower extremity. The condition has not responded well to over-the-counter hydrocortisone cream. The patient has experienced a similar condition in the past and denies any recent trauma or triggering events. The patient denies a family history of this condition.
Allergies:  
Penicillin, peanuts
Medications:  
Loratadine 10 mg once daily, Vitamin D 1000 IU once daily
Past Medical History:  
Eczema
Past Surgical History:  
Appendectomy in 2010
Past Family and Social History:  
Non-smoker, occasional alcohol use
Review of Systems:  
- Gastrointestinal: No symptoms reported  
- Musculoskeletal: No concerns mentioned  
- Integumentary: Recurring dermatitis flare-up  
- Hematologic/Lymphatic: No findings  
- Allergic/Immunologic: Seasonal allergies
Objective:  
The patient is appropriately dressed, articulate, awake, alert, and oriented x3, appears stated age, and looks to be in good health.
Vascular:  
Dorsalis pedis pulses are 2+ left, dorsalis pedis pulses are 2+ right, and posterior tibial pulses are 2+ left, posterior tibial pulses are 2+ right. Capillary filling time with the leg elevated is 2 seconds at the level of the digital tufts. There are no ischemic skin changes present in the right lower extremity. There is no edema noted in the right extremity. Digital hair is present.
Neurological:  
Epicritic sensation, including sharp-dull, light touch, proprioception, two-point discrimination, vibration, and protective threshold, are intact, without focal motor or sensory deficit in the right extremity. Normal muscle mass is appreciated in the lower extremity and foot on the right side. Mulder’s sign is negative in both feet.
Dermatological:  
There is erythematous scaling noted on the right lower extremity. There is no vesicle formation. Otherwise, no evidence of edema, ecchymosis, or signs of bacterial infection is noted in the lower extremities. No varicosities, telangiectasias, pigmented lesions, or signs of venous stasis changes are observed. Adequate fat padding is appreciated on the inferior aspect of each foot.
Musculoskeletal:  
One notes a neutral foot type with no gastroc-soleus equinus deformity. One notes no limb length discrepancy. Range of motion of the ankle, subtalar, and midtarsal joints is pain-free and within normal limits. There are no digital contractures noted in the digits. Muscle strength is 5/5 for all four lower extremity muscle groups.
Assessment:  
L30.9 Dermatitis, unspecified
Plan:  
Prescribed topical corticosteroid cream for application twice daily. Advised to avoid known allergens and irritants. Scheduled follow-up in two weeks. All questions were answered in detail, and the patient is instructed to return to the office in two weeks.