Eczema

Introduction

Dear Dr. [Referring Doctor's Last Name], I had the pleasure of seeing [Patient First Name], a [Patient Age]-year-old [Patient Gender] at the allergy clinic. [Patient First Name] was referred for an allergy assessment in the setting of atopic dermatitis.

History of Presenting Illness

[Provide a detailed narrative of the patient's eczema history, including the age of onset and specific areas affected such as hands, antecubital fossa, popliteal fossa, face, torso, and back. Discuss any known triggers or lack thereof, and note any secondary skin infections. Include information on whether the patient has seen a dermatologist and details of their treatment regimen, including moisturizers and other treatments used. Assess the overall control of eczema as poor, moderate, or good. Additionally, inquire about any consultations with an allergist, history of contact dermatitis, and completion of phototherapy.]

Allergy Review

[Insert the following text: The patient has no prior history of asthma, allergic rhinitis, medication allergies, venom allergies, or IgE-mediated food allergies]

Past Medical History

[List the patient's past medical history and number them.] For example: 1. [Condition 1] 2. [Condition 2] ...

Medications

[List the patient's current medications and number them.] For example: 1. [Medication 1] [Dosage] 2. [Medication 2] [Dosage] ...

Medication Allergies

[List any known medication allergies or state 'NKDA' if none.]

Social History

[Provide details about the patient's social history, including smoking, alcohol use, occupation, and any relevant lifestyle factors. Provide details about extended health benefits.]

Environmental History

[Describe the patient's living environment, including details about their home, pets, frequency of bedding washing and any potential environmental allergens.]

Family History

[List relevant family medical history, particularly any hereditary conditions, respiratory conditions or allergies.]

Chief Complaint

Eczema

Physical Exam

BP: [Insert BP], HR: [Insert HR] BPM [Insert the following text without editing it: [Patient's First Name] appears well. Head and neck examination was normal. Cardiac exam revealed a normal S1 and S2. Chest examination is clear with no wheezes or crackles. Skin examination did not reveal active eczema patches or urticaria lesions. The rest of the examination is unremarkable.]

Skin Test Results

[Insert the following text: Environmental Allergens: Positive skin test to dust mites, cat, dog, tree pollens, grass pollen, molds and weeds. Negative skin testing to dust mites, cat, dog, tree pollens, grass pollen, molds and weeds. Both histamine and saline control are appropriate.]

Plan

[Patient's First Name] has atopic dermatitis. They are sensitized to [insert allergens]. I recommend that they moisturize everyday with Vaseline, glaxal base emollient or CeraVe. I prescribed Betamethasone Cream BID PRN/Mometasone 0.1% ointment BID PRN/Clobetasol 0.05% ointment BID PRN/Eucrisa 2% BID PRN/Elidel 1% BID PRN, to be used on affected areas. Furthermore, I provided the patient with a written eczema skin care action plan and provided an online resource through eczemahelp.ca.]

Impression

[Provide a concise clinical impression based on the assessment.] For example: 1. [Diagnosis]

Plan

[Patient's First Name] has atopic dermatitis. They are sensitized to [insert allergens]. I recommend that they moisturize everyday with Vaseline, glaxal base emollient or CeraVe. I prescribed Betamethasone Cream BID PRN/Mometasone 0.1% ointment BID PRN/Clobetasol 0.05% ointment BID PRN/Eucrisa 2% BID PRN/Elidel 1% BID PRN, to be used on affected areas. Furthermore, I provided the patient with a written eczema skin care action plan and provided an online resource through eczemahelp.ca.]

Follow-up

[Specify the follow-up timeline and any specific instructions for future appointments.] For example: Follow-up: [Timeframe]

Closure

I appreciate the opportunity to participate in [Patient First Name]'s care, and I hope my suggestions are helpful. If any questions arise, please feel free to contact my office.