e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\patricia jill samples consolidated\06-04-12\060412 pjl.doc 7/28/2012 1:02: 15 PM 131072 1.

Actinic keratoses, three total were treated today, two on the scalp and one on the right temple with liquid nitrogen cryotherapy x2 cycles. Postprocedu ral care and expectations were discussed. The patient tolerated the procedure w ell. 3. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 6. We discussed monthly skin checks, looking for any new or changing pigmen ted lesions. We also asked the patient to look for an irregular border, asymmet ry, change in color or increase in diameter of any pigmented lesion. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Sandra presents to the office today status post excision of maligna nt melanoma on the right leg. Date of surgery, 05/22/2012. The patient is in t oday for a total skin exam. She gives a personal history of malignant melanoma recently diagnosed and excised by Dr. Lawrence Chang. She has no and/or tanning history, but does admit to blistering and sunburns as a child and gives no fami ly history of skin cancer. 1. History of malignant melanoma. We discussed monthly skin checks, looking for any new or changing pigmented lesions. We also asked the patient to look f or an irregular border, asymmetry, change in color or increase in diameter of an y pigmented lesion. 2. The importance of daily sun protection was discussed. The patient was g iven an informational brochure on skin cancer and a starter sample of a complete sun block. 4. Scar right medial right lower extremity, healing nicely. Aftercare was discussed with the patient. 5. Lentigines. The patient was reassured regarding the benign nature of th ese lesions. These lesions do, however, indicate diffuse sun damage. We discus sed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or grea ter whenever they are exposed to the sun. 6. Benign nevi. These are all well marginated, homogenously pigmented, sym metrical, benign-appearing moles. We reviewed the ABCD s of melanoma, and a hando ut detailing this information was given to the patient. The patient understands that if any of these lesions begin to change, they are to return to clinic for re-evaluation. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Neil presents to the office today as a new patient for a total skin exam. His wife had recently been diagnosed with malignant melanoma of the righ t lower extremity. He also has a family history of his mother having some skin cancers removed. He is unsure of which type. The patient denies any personal h istory of skin cancer, but does admit to blistering and sunburns as a child. He denies and/or tanning bed use. OBJECTIVE: Physical examination reveals a well-developed, well-nourished Caucas ian male, in no apparent distress. I did exam today the scalp, face, neck, trun k and bilateral upper and lower extremities including buttocks region and perine al region was also visualized at today s appointment as the patient does have a co ncern in that area. On examination of the face, neck and chest, he does have so me inflammatory papules and pustules consistent with acne vulgaris. He points t o area on the left upper cutaneous lip, which is a light tan macule with a somew hat irregular border, which looks to be consistent with solar lentigo. On exami nation of the trunk and upper and lower extremities, he does have a few symmetri cal benign-appearing nevi evenly pigmented and well circumscribed light to mediu m brown in nature 2-3 mm in diameter. He does have some fine flaking consistent

with xerosis of the plantar surface of the feet bilaterally. On examination of the perineal area, he points to growth of concern. This is a fleshy pedunculat ed growth consistent with skin tag. 1. Lentigo of concern left upper cutaneous lip. The patient was examined b y both myself and Robert J. Pariser today. He agrees with assessment and plan o f lentigo. He states that if it does become symptomatic to come in for treatmen t, which would consist of freezing the area. 2. Benign nevi. These are all well marginated, homogenously pigmented, sym metrical, benign appearing moles. We reviewed the ABCD s of melanoma, and a hando ut detailing this information was given to the patient. The patient understands that if any of these lesions begin to change, they are to return to clinic for re-evaluation. 6. Skin tag perineal region. We discussed monthly skin checks, looking for any new or changing pigmented lesions. We also asked the patient to look for a n irregular border, asymmetry, change in color or increase in diameter of any pi gmented lesion. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ASSESSMENT/PLAN: Dermatitis not otherwise specified. Pathology results consist ent with spongiotic dermatitis. This is likely a nummular eczema versus ACD. T he patient states he is good on topical steroids for treatment and will use this only as needed for flares. I have advised the patient should he get any more i mpetiginization more infectious areas to return to the office at once, otherwise followup will be open ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. The patient is clear today and denies any complications or side effects secondar y to medication as we have discussed before to include headaches, visual problem s, gastrointestinal side effects or changes in mood. OBJECTIVE: Physical examination reveals a well-developed, well-nourished young Caucasian male, in no apparent distress. I did examine today the face, neck, t runk, and bilateral upper extremities. The face and trunk are free and clear to day of any infectious or inflammatory papules or pustules. No comedonal pluggin g is noted as well. The Accutane has done excellent job of clearing up his once moderate case of acne vulgaris. He does appear to have approximately 25 to 30 symmetrical benign-appearing nevi ranging from light-brown to dark-brown in natu re and anywhere in size from 2 to 6 mm in diameter. They are all evenly pigment ed and well circumscribed at this point. However, I have advised the patient to keep watch given his history of sun exposure. 1. Acne vulgaris. Continuation of Accutane therapy sixth and final month. The patient will continue on standard dose of 1 tab p.o. b.i.d. I have written him for 60 tablets with no refills. He will continue on with the TriCor. He i s good on refills for that. We will see him back in 4 weeks for follow-up of th e acne. 4. We discussed monthly skin checks, looking for any new or changing pigmen ted lesions. We also asked the patient to look for an irregular border, asymmet ry, change in color or increase in diameter of any pigmented lesion. 5. The importance of daily sun protection was discussed. The patient was g iven an informational brochure on skin cancer and a starter sample of a complete sun block. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Sharlica presents today for a full body skin exam. She is also in for a recheck on the melanonychia on the right great toe and an ingrown hair of concern in the groin area. The patient denies any history of skin cancer person ally. She gives no family history of skin cancer either. She does have a perso nal history of hives and seasonal allergies. She admits to no blistering sunbur ns as child and denies tanning bed use as well. 2. Acne vulgaris with postinflammatory changes. I have given the patient s ome samples and coupons of Cetaphil Derma Control Wash and Lotion. I would like

for her to wash her face in the morning and then apply a thin coat of clindamyc in lotion to the face. At nighttimes, I am going to prescribe her Differin 0.3% gel one pump to the face at night starting out every other night, titrating up to nightly use as tolerated. She again may use the Cetaphil cleanser and the mo isturizer if needed to opposite dryness and irritation. 3. Nail disease with melanonychia of the right great toe. The patient was evaluated by both myself and Dr. Pariser today. He is not concerned with any fi ndings other than some hyperkeratosis of the right great toenail. He is advised of fungal culture. The patient states, she is going to treat initially over th e next few months with home remedy to include white vinegar soaks. If she is un satisfied with the treatment after three months, she can always call back in and if the culture is positive we can start a 90-day trial of Lamisil 250 mg 1 tabl et p.o. q.d. for 90 days with liver test done at approximately six weeks. Follow up will be in two to three months at the patient s convenience, otherwise w e will see her for her next total in June of 2013. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. PAST MEDICAL HISTORY: The patient does have a history of basal cell carcinoma o n the forehead, removed in the past successfully. 1. Actinic keratosis on the nasal bridge. Two lesions total were treated w ith liquid nitrogen cryotherapy x2 cycles. Post-procedural care and expectation s were discussed with the patient and she tolerated the procedure well. 2. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 6. History of basal cell carcinoma. We discussed monthly skin checks, looki ng for any new or changing pigmented lesions. We also asked the patient to look for an irregular border, asymmetry, change in color or increase in diameter of any pigmented lesion. 7. The importance of daily sun protection was discussed. The patient was g iven an informational brochure on skin cancer and a starter sample of a complete sun block. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Noel presents to the office today for a rash and itchy bump she has had for the last eight months. She has been using topical hydrocortisone cream for them and Benadryl, but she states that the Benadryl makes her itchy, so she only uses it at night. She does give a past history of having a cheap jewelry react in a skin rash fashion on the chest. She also has a history of keloids. The patient has a history of atypical nevi one removed on the back. She is in t oday for her upper body mole check as well. FAMILY HISTORY: The patient denies any family history of skin cancer, but does admit to tanning bed use more than 20 times in her life especially as a young te enager and blistering sunburns as a child. 1. Neoplasm uncertain, rule out AN versus DN versus MM. Under aseptic tech nique and 1% lidocaine the lesion was removed with a DermaBlade technique. Elec trodessication was applied to the base. A dry dressing with Polysporin was appli ed and wound care instructions were given. The proposed procedures, alternatives , risks and benefits were discussed with the patient. Follow up will be based o n the pathological diagnosis and as needed. The patient was informed that they will be made aware of the results in two to three weeks either by phone or via m ail. If they do not hear from us in four weeks they are to call us. This was d one in our office today by dermatology technician Tabby Starkey. 2. Dermatitis not otherwise specified, likely atopic dermatitis, but can ru le out ACD versus ICD. I have given the patient some Topicort cream to use twic e daily to the xerotic patches on the flexor folds of the wrist and Desonide lot ion, which she may apply twice daily as needed for flares on the face. The pati ent is using Dove soaps and Aveeno lotion. I have advised her that these fine t o use. She can also do Allegra for non drowsy daytime itch relief and then cont

inue on with her Benadryl at night 25 to 50 mg p.o. q.h.s. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: On exam, he is a well-developed, well-nourished Caucasian male, in n o apparent distress. Wound site on the dorsum of the left forearm is well heale d and well approximated. The patient presents for suture removal. Patient has no complaints about the surgical site, and the wound has healed without any comp lication. The wound was cleansed and sutures were removed. The patient was ins tructed to call me if there is any concern about the surgical site in the future . The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Mr. Kuzio presents today for a skin growth on the left forehead. H e states this has been there for approximately five to six months. It does not give any symptoms other than some itching. The patient denies any personal or f amily history of skin cancer. Denies any blistering or sun burns as a child, an d denies tanning bed use. OBJECTIVE: Physical examination reveals a well-developed, well-nourished Fitzpa trick type 4 male, in no apparent distress. I did examine the nodule on the lef t temple. The patient points to approximately 6 mm waxy brown stuck-on appearin g papule 7 mm in diameter consistent with irritative seborrheic keratosis that i s right at the hairline and is constantly traumatized by his brush. On examinat ion of the arms, he does have some symmetrical benign-appearing nevi 2 mm in med ium brown in nature evenly pigmented and well circumscribed. The patient then a lso points to one nevi on the right upper lip, which looks to be intradermal in nature. He says he has had it for 15 years and states that it has been stable t hroughout the whole time. It is flesh colored and well circumscribed, evenly pi gmented in nature and nonsymptomatic. It is 5 to 6 mm in diameter. 1. Irritative seborrheic keratosis. This was treated in the office today w ith liquid nitrogen cryotherapy x3 cycles. Postprocedure expectations were disc ussed with the patient. He tolerated the procedure well. 2. Benign nevi. These are all well marginated, homogenously pigmented, sym metrical, benign appearing moles. We reviewed the ABCD s of melanoma, and a hando ut detailing this information was given to the patient. The patient understands that if any of these lesions begin to change, they are to return to clinic for re-evaluation. We discussed monthly skin checks, looking for any new or changin g pigmented lesions. We also asked the patient to look for an irregular border, asymmetry, change in color or increase in diameter of any pigmented lesion. AB CD MACRO. I have advised the patient that the baseline total skin exam would be appropriate. Given that he does have quite a few number of moles, he states he will be scheduling this possibly at the end of the summer. At this point, foll ow up is open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Ms. Askew presents to the office today for followup of her patch te st placement at the request of Dr. Cyndi Torosky. The patient gives no personal or family history of eczema or psoriasis and states that she has had this over the last few years and it is quite itchy and uncomfortable. Dermatitis, not otherwise specified with xerosis, patch test placement recommend ed today in office by Cyndi Torosky, MD. Patch test was placed today in office by dermatology technician Tammy Starkey. Approximately, 10 to 15 minutes was sp ent in office explaining the patch test placement procedure with the patient. A ll concerns were addressed and questions answered in the office today. Of note, the patient is retired and denies any contact with abrasive chemicals that she knows of. We will follow up in 48 hours for a patch test read (acute) and then we will do the final followup at 96 hours for a delayed hypersensitivity reading . The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Ramon presents to the office today for dry, itching, and flaky skin

, which he was treated sometime ago by Dr. Robert Pariser. Last date of service was 11/22/2010. The PMS preparation was negative for tinea versicolor. The pa tient stated that he was given triamcinolone ointment at that time to put on twi ce daily and then there was some improvement, but it has worsened over the last couple of years. He is not currently on any medications nor is he allergic to a ny medications. He has never been used tanning bed. He is an occasional drinke r and nonsmoker. OBJECTIVE: Physical examination reveals a well-developed, well-nourished Africa n-American male, in no apparent distress. I did examine the area of concern on the chest, back, and arms. He does have fairly well-marginated and scaly somewh at hyperpigmented dermatitic areas to rule out tinea versicolor versus spongioti c dermatitis. The patient states that it does not keep him up at night, however . He is anxious for diagnosis. Dermatitis, not otherwise specified with hyperpigmentation and xerosis, rule out tinea versicolor versus spongiotic derm. After obtaining written consent, the patient was prepped with alcohol. Buffered lidocaine with epinephrine 1% was ad ministered for local anesthesia. The specimen was obtained with a 4 mm punch bi opsy. 4-0 nylon suture was placed. Drysol was used for hemostasis. Polysporin o intment was applied and the wound was bandaged. Wound care instructions were re viewed. The patient tolerated the procedure well. Pathology results will be ma iled to the patient. This was done in the office today by dermatology technicia n, Tammy Starkey. Clinically, this does appear to be consistent with the tinea versicolor for the next two weeks, so we are awaiting biopsy results, so I am ha ving the patient to resume use of ketoconazole shampoo as a trunk wash, apply to the affected area, leave on five minutes and rinse for two weeks. I rendered h im the large amount with a couple of refills. Also, I am going to have him appl y ketoconazole 0.1% cream to the affected areas twice daily over the next two we eks and see him back at the two-week followup for discussion of pathology result s. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: Physical examination reveals a well-developed, well-nourished Fitzpa trick type 4 male, in no apparent distress. I did examine the area of concern o n the left frontal/hairline region. There is a 1-cm cystic nodule present consi stent with likely epidermoid cyst versus neurofibroma. Also, on examination of the face, he does have some comedonal plugging in the paranasal and bilateral ma lar cheek region of the face. This is consistent with acne vulgaris comedonal c omponent. The patient does have some symmetrical benign-appearing nevi, _____ b rown in nature 2 to 3 mm in diameter on the face and arms. 1. Acne vulgaris mainly comedonal in nature. I have given the patient pers onalized acne regimen today that includes Cetaphil foaming face wash to be used q.a.m. and q.p.m. At night, he is to apply a small pea-sized amount of Epiduo t o the face. Side effects of retinoid therapy were discussed with the patient in the office today. He also understands he is to start twice weekly, titrating u p to every other night and then nightly use only if tolerated. 2. Neoplasm of uncertain left frontal forehead at the hairline. Rule out c yst versus neurofibroma. Special surgery consult was arranged with Dr. Lawrence Chang. Given that the patient desires the best cosmetic result possible and th is is a highly visible area. 3. Benign nevi on the face and arms. These are all well marginated, homoge nously pigmented, symmetrical, benign appearing moles. We reviewed the ABCD s of me lanoma, and a handout detailing this information was given to the patient. The pa tient understands that if any of these lesions begin to change, they are to retu rn to clinic for re-evaluation. 4. We discussed monthly skin checks, looking for any new or changing pigmen ted lesions. We also asked the patient to look for an irregular border, asymmet ry, change in color or increase in diameter of any pigmented lesion. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. CURRENT MEDICATIONS: Include: Bisoprolol/HCTZ, letrozole, losartan, Crestor, Z

etia, _____ omeprazole, levothyroxine, and vitamin D. She is allergic to niacin . She has never used a tanning bed. She is a social drinker and nonsmoker. Th e patient denies any personal or family history of skin cancer. She also denies any history of blistering sun burns as a child and denies tanning bed use ever. 1. Actinic keratoses two on the nasal bridge were addressed today. We have discussed options to include cryotherapy and Solaraze topical therapy. The pat ient has opted to do a twice daily trial of Solaraze to the two hyperkeratotic a reas on the nose. Expectations were discussed and instructions for use were giv en to the patient along with two samples, which should last her over the next 60 days. The patient has been advised if these continued to be symptomatic after two months of twice daily use, she will need to come in to the office for a cryo therapy followup. 2. Lentigines. The patient was reassured regarding the benign nature of th ese lesions. These lesions do, however, indicate diffuse sun damage. We discus sed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or grea ter whenever they are exposed to the sun. 3. Benign nevi These are all well marginated, homogenously pigmented, symme trical, benign appearing moles. We reviewed the ABCD s of melanoma, and a handout detailing this information was given to the patient. The patient understands t hat if any of these lesions begin to change, they are to return to clinic for re -evaluation. 4. Hemangioma The benign nature of the lesions was discussed and no treatme nt is necessary at this time. Follow up will be in one year unless the patient of course needs us sooner. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ASSESSMENT/PLAN: Seborrheic dermatitis with some xerosis. The patient will con tinue on with the desonide therapy use p.r.n. flares and the ketoconazole cream to the face use once daily as well. Prescription refills were written today in office for a 30 g tube of desonide with 1 refill and a 60 g tube of ketoconazole with two refills. She will continue on with the shampoo twice weekly to the sc alp and face as needed and I have also filled a prescription for clobetasol 0.05 % from one can to be used on the scalp again p.r.n. flares. Side effects of the topical steroid use were discussed with the patient to include skin thinning, a trophy, and telangiectasias. The patient voiced understanding. Follow up with me in three months. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Laura presents to the office today for a body check and an itchy mo le of concern on the left buttock. The patient states her medications include A viane, which is a birth control pill and a multivitamin. She is not allergic to any medications that she knows of. She does admit to the tanning bed has a you ng teen, 30 times or more in her life. She also does drink two drinks two times per week and is a nonsmoker. She does admit to some blistering sun burns as a child. She has a family history (her maternal grandfather) of basal cell carcin oma. She has no personal history of skin cancer. OBJECTIVE: Physical examination reveals a well-developed, well-nourished Caucas ian female, in no apparent distress. I did examine today the scalp, face, neck, trunk, and bilateral upper and lower extremities including buttocks region. Gr oin region was deferred at today s visit. On examination of the upper and lower b ody, she does have a few symmetrical benign-appearing nevi, light brown and medi um brown in nature, evenly pigmented and well circumscribed. She has some scatt ered solar lentigines across the base of the neck and upper shoulders. She does have some peeling from a sun burn present in the middle of the chest where she stated that she missed her sunscreen. On the left buttock, there is a 4-mm dark brown macule, which is darker than the rest of the nevi and in the area of no s un exposure. Given the patient s history of indoor tanning and blistering sun bur ns as a young child, this may clinically be suspicious for atypical nevus versus dysplastic nevus versus malignant melanoma. 1. Neoplasm of uncertain rule out AN versus DN versus MM: Under aseptic te

chnique and 1% lidocaine the lesion was removed with a DermaBlade technique. El ectrodesiccation was applied to the base. A dry dressing with Polysporin was app lied and wound care instructions were given. The proposed procedures, alternativ es, risks and benefits were discussed with the patient. Follow up will be based on the pathological diagnosis and as needed. The patient was informed that the y will be made aware of the results in two to three weeks either by phone or via mail. If they do not hear from us in four weeks they are to call us. This was done in office today by dermatology assistant, Tammy Starkey. 3. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. The importance of daily sun protection w as discussed. The patient was given an informational brochure on skin cancer and a starter sam ple of a complete sun block. I have advised the patient to follow up will be pe nding pathology results and I would like to see her back regardless of the resul ts for a one-year total skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Neoplasm uncertain of the left shoulder, rule out drying comedone versus recurrence of epidermoid cyst. After obtaining written consent, the patient wa s prepped with alcohol. Buffered Lidocaine with epinephrine 1% was administered for local anesthesia. The specimen was obtained with a 8 mm punch biopsy. 4-0 nylo n suture was placed. Drysol was used for hemostasis. Polysporin ointment was appli ed and the wound was bandaged. Wound care instructions were reviewed. The patient tolerated the procedure well. Pathology results will be mailed to the patient. T his was done in office today by dermatology technician, Tammy Starkey. Vertical mattress sutures were placed at today s office visit given the location. 4. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 3 0 or greater whenever they are exposed to the sun. Follow up will be in 10 to 1 4 days for suture removal. At that time, we will discuss removal of the second area of concern. This is approximately 2 cm adjacent and inferior to the one th at was treated today. I have discussed with the patient that it would be more p rudent to remove after the larger one has healed. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Stephanie presents to the office today starting a month full of Acc utane therapy. She does admit to some dryness of the lips and some minor arthra lgias of the knees and knuckles. She states this has kept at bay while with Adv il used p.r.n. pain. Patient has had blood work done earlier today at Sentara L ee Laboratory, results are not available as of yet. The patient denies any head aches or visual problems. She denies any gastrointestinal symptoms and denies a ny mood swings, depression or suicidal ideations. ASSESSMENT/PLAN: Acne vulgaris, postinflammatory changes and xerosis. Continui ng on with Accutane 40 mg tablets, one tablet p.o. b.i.d. starting a month for t oday. I have post dated her labs for July 1, 2012. She may obtain these at tha t time to include a fasting triglycerides, AST, ALT, and serum HCG. I have advi sed the patient once receive her labs dated today from Sentara Lee Laboratories and they are reviewed and normal, she will then be cleared to answer the questio ns in the iPLEDGE system and will then have seven days to follow up from that po int to pick up her medication. Follow up will be in four weeks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Tawan presents today coming by his mother for some firm flesh-color ed bumps on the facial and arm area. The patient s mother does relate a past hist ory of seasonal allergies. ASSESSMENT/PLAN: Keratosis pilares. I have given the patient some samples of E ucerin Plus Smoothing Essentials and I have advised them they may try this to im

prove texture of the area; however, I have informed the patient s mother that this is a benign skin condition and often times children will grow out of it; howeve r, there is no cure for it. Patient education handout was given to the mother t o share with her son at today s office visit. Followup at this point will be open ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: On exam, he is a well-developed, well-nourished Caucasian male, in n o apparent distress. On examination of palmar aspect of the left hand, he does have approximately four verrucous papules, some of the vesiculation is secondary to intense liquid nitrogen cryotherapy. There are no signs of impetiginization . The patient denies any fevers, sweats or chills since date of procedure. ASSESSMENT/PLAN: Verruca. I have advised both the patient and mother that this is appropriate reaction to the aggressive liquid nitrogen cryotherapy. They ha ve been advised to start salicylic acid topical once the warts have calm down. I have advised them that it is appropriate to begin therapy at this time. They will either do the Verisol topical liquid, which has automatic occlusive film up on painting on or they may opt to do the wart dots, which have a salicylic acid in them as well. Follow up will be on an open ended basis. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Lisa presents to the office today for total skin exam and some area s of concern. She states she has been recently exposed to MRSA (her granddaught er). She is concerned, she may have this as well. The patient has a history of gastric bypass in 2010. She also gives a history of herpes, to which she has h ad outbreaks on the body. She also is interested in getting intravenous ablatio n done on the anterior surface of the right lower extremity and has talked to Dr . Chang about this in the past. The patient denies any personal or family histo ry of skin cancers. She does admit to blistering sunburns as a child and _____ tanning too many times to count (over 20 times in her life). OBJECTIVE: On exam, she is a well-developed, well-nourished Caucasian female in no acute distress. I examined her head, neck, chest, back, abdomen, bilateral arms, legs and feet and her bilateral elbows. On her left upper shoulder, she d oes have a small inflammatory papule, which looks to be in the final stages of r esolution with a little bit of surrounding erythema. She also does have varicos ity present on the tibial surface of the right anterior extremity consistent wit h varicose veins. On examination of the right buttock, she does have a light ta n macule approximately 8-9 mm in size consistent with lentigo. As the patient d oes tan this area, it is not uncommon for this to occur. 1. Dermatitis otherwise specified of the left shoulder. No pustules were n oted today, nothing that would be of any value with regards to bacterial culture . I have reassured the patient that this does not look like anything more than a resolving inflammatory papule. However, I have given her a small tube of mupi rocin ointment to put on there twice daily over the next week. If it has not re solved in one week, she may return to the office for reassessment. 2. Likely resolving ruptured hair follicle, I have given the patient 15 g t ube of mupirocin to be applied twice daily for one week. If it does not improve , we would like to see her back. 3. With regards to the patient s varicose veins, I have referred her for a sp ecial endovenous ablation consult with Dr. Lawrence Chang. 4. We did the lentigo on the right buttock. Lisa was reassured that these are benign lesions. They do, however, indicate diffuse sun damage. We discusse d the importance of wearing a broad-spectrum sunscreen with an SPF of 30 or grea ter whenever she is exposed to the sun. A handout of recommended broad-spectrum sunscreens was given to the patient as well as numerous broad-spectrum sunscree n samples. Followup at this point is open ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Allergic contact dermatitis likely secondary to nickel with id reaction on the arms. I have given the patient prescription for one-pound jar of the tri

amcinolone ointment to be applied twice daily as needed with no refills. For mo isturization of her dry skin, I have advised Vaseline and Cetaphil 50:50 mix to be done especially after bath time or shower time, but also one additional time during the day each day. 2. Keratosis pilares. I have advised the patient of this benign skin condi tion, no treatment is warranted. Followup will be on an open-ended basis. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\patricia jill samples consolidated\06-05-12\060512 pjl.doc 7/28/2012 1:02: 17 PM 131072 OBJECTIVE: Physical examination reveals a well-developed, well-nourished Caucas ian female, in no apparent distress. I did examine today the scalp, face, neck, trunk, and bilateral upper and lower extremities including the buttocks region. Groin region was deferred at today s visit. On the collar/neck line area of the neck, the patient does have numerous fleshy pedunculated growths consistent with skin tag. A couple are present on the trunk as well. Sun exposed areas of the upper and lower bodies show numerous light-tan, light-brown macules of various shapes and sizes consistent with solar lentigines. She also does have some symm etrical benign-appearing nevi, light-brown to medium-brown in nature on the ches t and trunk. There is one particularly dark brown nevi 9 mm x 4 mm ovoid in sha pe, which we will continue to monitor clinically. It has been evaluated before with her primary care doctor and another dermatologist and has remained stable t hroughout her lifetime. She does have some generalized fine flanking and xerosi s of the plantar aspects of the feet bilaterally. 1. Benign nevi. Today I reviewed sun protection guidelines. I discussed ABCD s a nd the use of sunscreen. I also recommended monthly self skin exam. The patient understands we should be notified for any changing lesions, new, or concerning l esions. I also discussed the use of wearing a hat and avoiding outdoor sun expos ure at the peak sun hours. We discussed monthly skin checks, looking for any ne w or changing pigmented lesions. We also asked the patient to look for an irreg ular border, asymmetry, change in color or increase in diameter of any pigmented lesion. 2. Lentigines. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 3. Skin tag. The patient was informed of the benign nature of these lesions an d no treatment is necessary at this time. Additionally one that was particularl y bothersome on the right neck was removed as a courtesy to the patient via ster ile snip procedure. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Verruca on the left lateral foot. This was treated in the office today with liquid nitrogen cryotherapy x3 cycles. Postprocedural care and expectations we re discussed with the patient and she tolerated the procedure well. 3. Lentigo. The patient was reassured regarding the benign nature of these les ions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whe never they are exposed to the sun. 3. Acne vulgaris/postinflammatory hyperpigmentation. Areas of involvement incl ude periorofacial region as well as the back. This is primarily inflammatory in nature and I have given the patient personalized acne regimen to include Cetaph il Derma Control oil-free wash to be used both daily and nightly. I am also goi ng to have her take a Solodyn 45 mg extended release tablet once daily for the n ext month to 2 months. I have written her for 60 tablets. At night, she is to apply a pea-sized amount of Epiduo to the face. Side effect s of the topical retinoid as well as the Solodyn therapy were discussed and revi ewed with the patient. She voiced understanding. I have also given the patient

some Cetaphil moisturizer Derma Control line in the event she experiences dryne ss secondary to the topical retinoids and it does have a sunscreen in it as well . 4. Benign nevi. These are all well marginated, homogenously pigmented, symmetr ical, benign appearing moles. We reviewed the ABCD s of melanoma, and a handout d etailing this information was given to the patient. The patient understands tha t if any of these lesions begin to change, they are to return to clinic for re-e valuation. Today I reviewed sun protection guidelines. I discussed ABCD s and the use of sunscreen. I also recommended monthly self skin exam. The patient unders tands we should be notified for any changing lesions, new, or concerning lesions . I also discussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours. We discussed monthly skin checks, looking for any new or c hanging pigmented lesions. We also asked the patient to look for an irregular b order, asymmetry, change in color or increase in diameter of any pigmented lesio n. Follow up will be in 2 months to reassess the acne and total skin exam will be made for 1 year from today s date. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ASSESSMENT/PLAN: Plaque-type psoriasis with scalp involvement and breakthrough plaques on the lower extremities, elbows and postauricular region. For the scal p and postauricular region, I have given the patient Clobex spray 125 mL bottle with 2 refills, it should last through the year. I have also written her for 60 g tube of Taclonex ointment with 4 refills, which should last through the year as well for control of her breakthrough plaques. She is continuing to be monito red for her Enbrel by her rheumatologist Dr. Reed. Follow up for her with our office will be in 1 year unless she needs us sooner. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Norma presents to the office today for suture removal on the left c hest. This patient denies any oozing, bleeding, crusting or drainage from the w ound, nor any fever, sweats, or chills. The patient presents for suture removal . Patient has no complaints about the surgical site, and the wound has healed w ithout any complication. The wound was cleansed and sutures were removed. The patient was instructed to call me if there is any concern about the surgical sit e in the future. This was done in the office today by Mandi Dejulio. Pathology results were discussed with the patient consistent with lichen simplex chronicu s. She voiced understanding. Follow up will be open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Lori presents to the office today for some possible cancerous spots in the arms and shoulders, which she has had over the last six to nine months. She does have a history of basal cell carcinoma been removed on her chest. She is unsure of which type of basal cell carcinoma it was. The patient is current ly taking Nasonex for allergies. She does have a history of seasonal allergies and has had history of gestational diabetes when pregnant. She denies any famil y history of skin cancer. Denies tanning bed use and denies blistering sunburns as a child. She is a nondrinker and nonsmoker. OBJECTIVE: Physical examination reveals a well-developed, well-nourished Caucas ian female, in no apparent distress. I did examine today the scalp, face, neck, trunk, and bilateral upper and lower extremities including the buttocks region. On sun exposed areas of the body, she has numerous light tan and light brown m acules of various shapes and sizes consistent with solar lentigo. She also does have on the left chest a well-healed, well-approximated scar from removal of he r basal cell carcinoma, which the patient states was done by another office back in 2003 or 2004, she is unsure which year exactly. On examination of the trunk , she has numerous symmetrical cherry red papules consistent with cherry hemangi oma as well as a couple of warty and waxy stuck-on appearing plaques and papules , one on the medial aspect of the left knee and one on the left temple, both con sistent with stucco keratoses. There is a fine plaquing consistent with a xeros is on the plantar aspects of the feet bilaterally. On the right forearm, she do

es have a 3-mm ill-defined patch of erythema, rule out SBCC versus Bowen s versus other. The patient does state that this is how the other one that she had remov ed on the chest presented; therefore, we are doing a biopsy of the area today. 1. Neoplasm uncertain of the right arm, rule out SBCC versus Bowen s versus other . After obtaining written consent, the patient was prepped with alcohol. Buffe red Lidocaine with epinephrine 1% was administered for local anesthesia. The le sion was removed in its entirety via a shave procedure with a Dermablade. Dryso l was used for hemostasis. Polysporin ointment was applied and the wound was ba ndaged. Wound care instructions were reviewed. The patient tolerated the proce dure well. Pathology results will be mailed to the patient. 2. Lentigines. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 4. Subcancer. The patient was informed of the benign nature of these lesions a nd no treatment is necessary at this time. 6. History of BCC with a well-healed scar on the left chest. We discussed mont hly skin checks, looking for any new or changing pigmented lesions. We also ask ed the patient to look for an irregular border, asymmetry, change in color or in crease in diameter of any pigmented lesion. Today I reviewed sun protection gui delines. I discussed ABCD s and the use of sunscreen. I also recommended monthly s elf skin exam. The patient understands we should be notified for any changing le sions, new, or concerning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours. Follow up will be pending pathology results, otherwise if the results do come back as benign then we will see her back in 1 year for her next total skin exam given her prior history. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: On examination, he is well-developed, well-nourished Fitzpatrick typ e I male, in no apparent distress. I did examine today the scalp, face, neck, t runk, and bilateral upper and lower extremities including the buttocks region. Groin region was deferred at today s visit. On examination of the vertex scalp, h e does have approximately eight ill-defined waxy erythematous plaques consistent with actinic keratoses, hyperkeratotic in nature. There is also one present on the left tragus, one on the left pinna, one on the right postauricular region, and one on the left mandible, all four which are also consistent with actinic ke ratoses. On the left mandible, there is a hyperkeratotic papule, rule out SCC v ersus hypertrophic actinic keratoses. The patient states he has had over the la st few months. On the right hip, he does have a large fleshy pedunculated growt h consistent with large skin tag. He also does have too numerous to count solar lentigo scattered about the sun exposed areas of the scalp, face, neck, trunk, and bilateral upper and lower extremities. On the trunk, he also does have some symmetrical cherry red papules consistent with cherry hemangioma and some warty , waxy, stuck-on appearing papules and plaques, flesh-colored to medium brown in nature consistent with seborrhoic keratosis. 1. Actinic keratoses, approximately 12 were treated in the office today with li quid nitrogen cryotherapy x2 cycles. Postprocedure care and expectations were d iscussed with the patient. He tolerated the procedure well. 2. Neoplasm of uncertain of the left mandible. Rule out SCC versus HDAK. Afte r obtaining written consent, the patient was prepped with alcohol. Buffered Lid ocaine with epinephrine 1% was administered for local anesthesia. The lesion wa s removed in its entirety via a shave procedure with a Dermablade. Drysol was u sed for hemostasis. Polysporin ointment was applied and the wound was bandaged. Wound care instructions were reviewed. The patient tolerated the procedure we ll. Pathology results will be mailed to the patient. 3. Skin tag right hip. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. 4. Lentigo. The patient was reassured regarding the benign nature of these les ions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whe

never they are exposed to the sun. 7. History of BCC. We discussed monthly skin checks, looking for any new or ch anging pigmented lesions. We also asked the patient to look for an irregular bo rder, asymmetry, change in color or increase in diameter of any pigmented lesion . Today I reviewed sun protection guidelines. I discussed ABCD s and the use of s unscreen. I also recommended monthly self skin exam. The patient understands we should be notified for any changing lesions, new, or concerning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours. I have also discussed with the patient the importance of good sunsc reen. The importance of daily sun protection was discussed. The patient was giv en an informational brochure on skin cancer and a starter sample of a complete s un block. Follow up will be pending pathology results; however, if they do come back returned as benign, then we will see Mr. Rose back in 1 year for his next total skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: Physical examination reveals well-developed, well-nourished Caucasia n female, in no apparent distress. I did examine today the scalp, face, neck, t runk, and bilateral upper and lower extremities. On examination of the scalp, i t is free and clear of any inflammatory or infectious entity on the face and aro und the sun exposed areas of the upper and lower body. She does have numerous l ight tan and light brown macules various shape and sizes consistent with solar l entigines as well as couple of warty waxy stuck-on appearing papules, flesh-colo red and medium brown colored on the trunk consistent with seborrhoic keratoses. She does have some generalized xerosis in the form of fine flaking on the plant ar aspects of the feet bilaterally. On the right hip, she does have some sclero tic looking patches on the right abdomen extending toward the umbilicus consiste nt with her biopsy-proven lichen sclerosus atrophicus. The patient states that it is asymptomatic at this time. 1. Lichen sclerosus atrophicus on the right hip asymptomatic. The patient is f ine with continuing to motor at this time and it is not providing any discomfort or symptoms to her. 4. Lentigo. The patient was reassured regarding the benign nature of these les ions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whe never they are exposed to the sun. Follow up in 1 year for the next total skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Mr. Lomibao presents today in office for suture removal on the left anterior chest. The patient denies any fever, sweats or chills, nor any abnorm al oozing, bleeding, crusting or drainage from the wound. The patient presents for suture removal. The patient has no complaint about the surgical site and th e wound has healed without any complication. The wound was cleansed and sutures were removed. The patient was instructed to call me if there is any concern ab out the surgical site in the future. This was done in the office by dermatology technician, Mandi Dejulio. Dictation is unavailable from the physician who had performed the biopsy. I have advised Mr. Lomibao that once he has received the pathology report, the treatment plan will be _____ at that time and he will be contacting the patient. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Ms. Skinner presents today with some rashes and pigment problems, p rimarily in the cleavage area of the chest and on the flexor surface of the uppe r arms bilaterally. She also has involvement on the mid axillary line of the le ft flank. The patient gives no other personal history of skin problems. She st ates that it is asymptomatic and does not itch. She does notice slight flaking to it. Mother has a personal history of lichen planus. For Chelsie s dry skin, s he has used Eucerin and Jergens. She states that gold jewellery causes a rash w hen it contact with her skin. The patient is not trying to get pregnant. She is

a nondrinker. She does smoke tobacco. She has used a tanning bed approximatel y 10 times in her life. She is also in today for concerns of acne. 1. Dermatitis, not otherwise specified, likely tenia versicolor versus lichen s clerosus atrophicus versus striae. I have seen this patient today with Dr. Moll y Smith. She would like to treat first for tenia versicolor before doing a biop sy. Given the extent of involvement over the chest, back and arms, I am going t o treat with oral fluconazole 150 mg tablet take 1 tablet q. week times 3 to 4 w eeks. I have given the patient a prescription for 4 tablets. Additionally, she may have to use ketoconazole shampoo as a body wash, leave on 5 minutes and the n rinse 2 to 3 times weekly in the shower. 2. Acne vulgaris with some ice-pick scarring on the face. The patient has a mi ld amount of inflammatory involvement at this time. I advised regimen for the p atient to include Cetaphil Derma Control oil-free wash twice daily as well as th e Derma Control moisturizer and that at night she is to apply pea-size amount of Epiduo Gel to the face. She is to do one pump to the face every other night ti trating up to nightly use only as tolerated. A 45 g tube was written at today s o ffice visit. We will follow up in 4 weeks to reassess the dermatitis. I have a dvised the patient that the discoloration symptoms may last for some amount of m onths; however, she should notice a significant decrease in the flakiness of the areas, especially on the left flank region if this is indeed true tenia versico lor. If no improvement is noted, we will be following up with biopsy at 4 weeks . The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Ms. Parmeley presents to the office today for some acne scars and lu mps on the face. She has had an extensive history of milia cyst and sebaceous hy perplasia treated in the past via electrodesiccation and/or Retin-A creams. The patient states that she has used Retin-A for the last two years and has noticed no significant result with regards to the amount of milia cyst/sebaceous hyperp lasia and states it has not improved the situation. She has been into tanning b ed approximately 20 to 30 times in her life. OBJECTIVE: Physical examination reveals a well-developed, well-nourished Caucas ian female, in no apparent distress. I did examine the areas of concern the pat ient points to the right bitemporal region. On palpation, there is a 5-mm fluct uant nodule consistent with likely epidermal inclusion cyst. No _____ visualize d at today s office visit. There has been also present 5 mm in diameter on the le ft temporal region as well. On examination of the face, the patient does have s ome flesh-colored dome-shaped papules consistent with sebaceous hyperplasia. Th ere are also some small calcified papules consistent with milia cyst and some ac ne scarring and ice-pick like scarring on the chin from older acneiform lesions in the past. ASSESSMENT/PLAN: Milia/cyst and sebaceous hyperplasia, bothersome to the patien t cosmetically. I have advised the patient to meet with our cosmetic/dermatolog ic surgeon Dr. Lawrence Chang for discussion of either laser resurfacing for the sebaceous hyperplasia and/or excision of the 2 small cysts on the bitemporal re gion. I have informed the patient that Dr. Chang does not do anything cosmetica lly for acne scarring; however, she may opt to do some laser resurfacing for all of her improvement of her skin texture. The patient is interested in setting a n appointment up to meet with Dr. Lawrence Chang on a Tuesday, Wednesday or Thur sday at the medical office. We will be setting that up at today s office visit. In the meantime, she will continue on with the Retin-A therapy for her sebaceous hyperplasia and milia cyst. I have advised the patient that if she would like to go from a Atralin 0.05% gel to a stronger 0.1% cream or gel such as Tazorac, I am happy to write that for her in the future if she so desires. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Lorraine is a new patient who presents to the office today for a mo le/spot and freckle check. She states that she has no personal history of skin cancer, but that her mother has had several skin cancers removed, she is unsure of which type. The patient admits to blistering and sunburns as a child, but le

ss 20 times in her life. She does have a history of high cholesterol. She is n ot trying to get pregnant. OBJECTIVE: Physical examination reveals a well-developed, well-nourished Caucas ian female, in no apparent distress. I did examine today the scalp, face, neck, trunk, and bilateral upper and lower extremities including the buttocks region. Groin region was deferred on today s office visit. On examination of the sun ex posed regions of the upper and lower body, she has numerous light tan, light bro wn macules, shapes and sizes consistent with solar lentigines. She also does ha ve some fleshy pedunculated growths on the trunk consistent with skin tag and so me symmetrical cherry red papules on the trunk as well consistent with cherry he mangioma. On examination of the upper and lower extremities and the trunk, she also does have some light tan to medium brown warty waxy stuck-on appearing papu les consistent with seborrhoic keratosis and at least 50 benign nevi, all of whi ch appear to have ill-defined borders. I have informed the patient that her nor mal seems to be ill-defined borders. They all range anywhere from 2 to 6 mm in diameter and are medium brown in color. 3. Lentigines. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 4. Skin tag. Skin tag. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. 5. Benign nevi. These are all well marginated, homogenously pigmented, symmetr ical, benign-appearing moles. We reviewed the ABCD's of melanoma, and a handout detailing this information was given to the patient. The patient understands t hat if any of these lesions begin to change, they are to return to clinic for re -evaluation. Today I reviewed sun protection guidelines. I discussed ABCD s and the use of sunscreen. I also recommended monthly self skin exam. The patient u nderstands we should be notified for any changing lesions, new, or concerning le sions. I also discussed the use of wearing a hat and avoiding outdoor sun expos ure at the peak sun hours. We discussed monthly skin checks, looking for any ne w or changing pigmented lesions. We also asked the patient to look for an irreg ular border, asymmetry, change in color or increase in diameter of any pigmented lesion. Follow up in 1 year for the next total skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: On exam, she is well-developed, well-nourished Caucasian female, in no apparent distress. Alert and oriented. I did examine today the scalp, face, neck, trunk, and bilateral upper extremities. On the sun exposed areas of the upper body, she has numerous light tan, light brown macules of various shapes an d sizes consistent with solar lentigo, couple of which have recently appeared on the right neck and also larger one on the right eyebrow. I have reassured the patient benign nature of this growth. She also has some warty waxy stuck-on app earing papules and plaques on the trunk as this was seborrheic keratosis, flesh colored to medium brown in nature. One particularly irritated bothersome on the left mid axillary line. On the left chest, she does have ill-defined waxy scal y plaque on the erythematous space consistent with actinic keratosis and she doe s have some waxy area on the right lateral aspect of the right eyebrow as well c onsistent with actinic keratosis. 1. Actinic keratosis on the left chest. This was treated with liquid nitrogen cryotherapy x2 cycles. Postprocedural care and expectations were discussed with the patient and she tolerated the procedure well. For the actinic keratosis on the right eyebrow, we are going to treat with solar rays twice daily for 2 mont hs as this has produced good results for the patient in the past. Sample was gi ven to the patient in office today for her to use. 2. Irritated seborrheic keratosis in the left mid axillary line, _____ freeze w as done to the patient with liquid nitrogen cryotherapy x3 cycles. Postprocedur al care and expectations were discussed with the patient and she tolerated the p rocedure well. 3. Lentigines. The patient was reassured regarding the benign nature of these

lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater w henever they are exposed to the sun. Follow up will be on an open ended basis. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Lorraine presents today for suture removal on the lateral aspect of the left ankle/left lateral malleolus. The patient states no fever, sweats, or chills and stated biopsy and no oozing, bleeding, crusting or drainage noted fr om the wound. The patient presents for suture removal. Patient has no complain t about the surgical site and the wound has healed without any complication. Th e wound was cleansed, suture were removed. The patient was instructed to call m e if there is any concern about the surgical site in the future. This was done in our office by dermatology technician, Mandi Dejulio. The wound is well heale d and well approximated. Aftercare was discussed with the patient and her husba nd who is accompanying her in the office today. They did voice understanding. I have advised the patient that the preliminary tissue cultures have come back a nd the acid fast bacterial culture and smear is still pending as is the fungus c ulture. I have discussed with the patient that the area of bacteria culture has shown no growth in 36 to 48 hours and that is the final report for that one. T he patient voiced understanding. I have advised the patient once the final repo rt is in and Dr. Molly has reviewed it, she will be back in touch with the patie nt at that time. They voiced understanding. Follow up pending lab results. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Carol presents today for suture removal on the left chin. The pati ent denies any fever, sweats, or chills nor any abnormal oozing, bleeding, crust ing, or drainage from the wound site. On examination of the left chin, there is a well-healed, well-approximated suture site. The patient presents for suture removal. Patient has no complaint about the surgical site and the wound has hea led without any complication. The wound was cleansed, suture were removed. The patient was instructed to call me if there is any concern about the surgical si te in the future. This was done in office today by dermatology assistant, Amand a Moore. Wound care was discussed with the patient. I have advised her that pa thology results should be available in the approximately one week. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Mr. Radford presents today for a rash on his lips and around his mo uth. He states he has had it for the last week. The patient states no changes in facial wash, toothpaste and no difference in gum or mint, no new foods and no new medications. He states it happened in early March and seemed to resolve wi th lip balm. His wife had also given him some betamethasone valerate cream, but states that now lips are dry, cracked, and peeling. 1. Dermatitis, not otherwise specified with xerosis. I have given the patient desonide ointment to be used in conjunction with ketoconazole cream. He is to a pply both of these twice daily over the next 2 weeks. I would like for him to f ollow back up in 1 week. If no significant improvement is noted at that time, w e may decide to switch up therapy. 2. Lentigines. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater w henever they are exposed to the sun. Follow up in 1 week. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ASSESSMENT/PLAN: Papular rosacea. I have written the patient for a year supply of the doxycycline 50 mg caps at today s visit. He states that the MetroGel has not helped. I have offered to give him some Finacea samples, but none were in o ffice today. Therefore, I have advised the patient should he call up in the nex t few weeks once we have restarted our supply we would be happy to give him a co uple of samples to try and if he likes the azelaic acid topical I would be happy to write him for a topical prescription for that. At this point, follow up wil

l be in 1 year. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Neoplasm uncertain, rule out verruca versus KA-type SCC. After obtaining wr itten consent, the patient was prepped with alcohol. Buffered lidocaine with ep inephrine 1% was administered for local anesthesia. The lesion was removed in i ts entirety via a shave procedure with a Dermablade. Drysol was used for hemost asis. Polysporin ointment was applied and the wound was bandaged. Wound care i nstructions were reviewed. The patient tolerated the procedure well. Pathology results will be mailed to the patient. 2. Lentigo. The patient was reassured regarding the benign nature of these les ions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater when ever they are exposed to the sun. 4. Subcancer. The patient was informed of the benign nature of these lesions a nd no treatment is necessary at this time. 5. BCC. We discussed monthly skin checks, looking for any new or changing pigm ented lesions. We also asked the patient to look for an irregular border, asymm etry, change in color or increase in diameter of any pigmented lesion. Today I reviewed sun protection guidelines. I discussed ABCD s and the use of sunscreen. I also recommended monthly self skin exam. The patient understands we should be notified for any changing lesions, new, or concerning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours . I have advised the patient the follow up will be pending pathology results. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Kathleen presents today for acne followup as well as wart of concer n on on the right foot fourth toe. She states that it has failed conventional t reatments to include Compound W wart therapy as well as liquid nitrogen cryother apy. She is in today for a discussion of treatment. The patient is an Irish da ncer and is looking for a noninvasive approach at this time if possible. She st ates that the acne treatment that she was given to include Tazorac gel, Differin gel, Acanya, and salicylic acid washes had only resulted in further irritating her face. I explained to the patient that the use of topical retinoid therapy c an be somewhat irritating and that is to be expected. The patient stated that a fter she discontinued all products she felt as if the case of her acne had gotte n better, say for some generalized erythema in the bilateral malar cheeks region . When I asked the mother who had accompanied her on today s visit, if there is a family history of rosacea, she did confirm that there is indeed a family histor y of rosacea. She also had been given doxycycline in the past, which she is sti ll taking. That is the only part of the regimen she has had ear tube. She has done T gel occasionally to the face as a facial soak she does not remember tryin g the ketoconazole shampoo. She has used the Clobex shampoo. OBJECTIVE: On examination, she is a well-developed, well-nourished young Caucas ian female accompanied by her mother, in no apparent distress. On examination o f the dorsum of her right fourth toe, there is a large exophytic verruca measuri ng approximately 1.3 cm in size having failed liquid nitrogen treatment, canthar idin, and home salicylic acid treatments. I have discussed with the patient Can dida antigen injection as well as debulking with local anesthesia. The patient s mother states she still has a rigorous dancing schedule and I was wondering if t here was anything else that we could possibly try that would not be required as invasive. On examination of the face, she does continue to have some mild eryth ema in the perinasal and periorofacial region. There is some fine flaking prese nt indicating this may be seborrheic in nature and given her family history of r osacea she may have a component of this as well. No inflammatory papules or pus tules are noted on today s visit. Some mild comedonal involvement on the nose. O n the forehead, she does have some pinpoint papules, which look more consistent with a yeast folliculitis than acneiform. 1. Grade 1 inflammatory acne with amount of comedone component. We will contin ue her on doxycycline 50 mg for the final remaining month of her prescription at

that time. The patient has desire to discontinue medication to see if she flar es or not. If she does flare, we will go back on the 50 mg once daily dosing as this is a low dose. I have explained this to the mother and patient today in o ffice. 2. Seborrheic dermatitis with yeast folliculitis. I am going to have the p atient try a ketoconazole shampoo as a scalp soak as well as facial wash once da ily over the next 2 weeks then go down to twice weekly for maintenance to see th is will help clear up the area on the forehead. 3. Persistent verruca on the dorsum of the right fourth toe. I am going to do a trial of Aldara, apply three to five times weekly for a period of six week s. I have informed the patient of the risks and benefits associated with topica l Aldara therapy as well as the side effects and I have advised her that. There is a chance that this may not clear with the use of the topical Aldara therapy. The patient and mother understand and wish to try this route regardless. Foll ow up will be in six to eight weeks. With regards to the acne, I have given her some samples of Cetaphil Derma Control for early skin wash as well as the moist urizer. I would like for her to use this in conjunction with her doxycycline. I have advised the patient after she goes of her final dose of doxycycline. She will most likely need to begin use of the topical Differin and/or topical Tazor ac along with Acanya use q.a.m. to help maintain her results. The patient voice d understanding followup in six to eight weeks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ADDENDUM: I have also discussed if the patient is aversive or irritated by the retinoids. We also may wish to try the Finacea given her family history of rosa cea. We do not have any samples today; however, at follow-up I will definitely keep this in mind. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Acne excoriated. We revisited the etiology of this problem. I have talked with the patient today about talking with her primary care provider with regards to treatment for OCD to involve SSRI therapy for obsessive-compulsive disorders such as picking. I have advised the patient that she needs to get the behavior under control prior to doing any type of revision surgery or procedure such as laser resurfacing for acne scarring as continued picking will only lead to new s cars. The patient is very aware of her problem and states that she would like t o get this under control prior to seeking cosmetic treatment. She will be conta cting her family care provider to discuss more about treating the behavioral pro blem of picking at the acneiform lesions. In the interm, I am going to give her Cetaphil Cleanser Derma Control oil-free wash and moisturizer. Samples were pro vided at today s appointment as well as coupons. She may get this over-the-counte r. I also have given her a refill 60 g tube of Aczone gel, which she may use tw ice daily. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Nailah presents today accompanied by her mother for some rash, bums , and itching that she has had over the last three months. She does give a chil dhood history of eczema. She has only used Benadryl and calamine lotion on thes e areas. She states it is worse on her hands. It starts out as some dry bliste rs up and down the fingers and that it is highly pruritic. She also describes s ome itching in the inner thigh area and vaginal region. The patient uses Dove s oap, which is scented. She also does use fragrance sprays and soaps. She is a nondrinker and nonsmoker. She is not allergic to any medications nor she is on any daily medications. OBJECTIVE: Physical examination reveals a well-developed, well-nourished Africa n American young female accompanied by her mother. The patient is in no apparen t distress. She is alert and oriented. On examination of the hand, she does ha ve some small 1-mm vesicles on the finger pads and dorsum of the fingers bilater ally consistent with dyshidrotic eczema. They are dry in nature. No sign of in fection is noted or impetiginization. On examination of the inguinal folds bila

terally, she does have some lichenified thickened hyperpigmented patches present in this region as well, which looks to be consistent with lichen simplex chroni cus likely due to an atopic flare. She does also have some generalized xerosis of both the upper and lower extremities bilaterally. ASSESSMENT/PLAN: Atopic flare with a dyshidrotic component and some postinflamm atory hyperpigmentation and overall dryness. I have advised the patient and her mother to discontinue all fragrance products for a period of two weeks. I woul d like for her to use in the interim Cetaphil Restoraderm. I have given her sam ples and coupons in office today, she may obtain these at her local drug store. I have also advised for non-drowsy daytime itch relief Children s Allegra to be d osed according to the instructions over-the-counter. At night, I have written h er for Atarax 25 mg. The patient is 125 pounds, she may take the adult dose of 125 mg tablet at night. I have informed the patient and her mother this may cau se drowsiness. They voiced understanding. For the hands and non-delicate skin areas, I have written for Topicort 0.25% cream. I would like for her to apply t his twice daily over the next two weeks p.r.n. flare/itch. I have written for a 60 g tube with a couple of refills. With regards to the delicate skin region o f the inguinal fold and vaginal area, I have written the patient for desonide cr eam a 60 g tube apply to effected area twice daily as needed for flares. We wil l follow up with patient in two weeks to reassess. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 2. Telangiectasia in the form of spider veins on the upper thighs. I have disc ussed with the patient sclerotherapy treatment with Dr. Lawrence Chang. I have given her his information and number. She states she will be following up with him for cosmetic removal of her telangiectasias (spider veins). 4. Lentigo. The patient was reassured regarding the benign nature of these les ions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whe never they are exposed to the sun. Providing she responds well to the Cortibalm , we will see her back next year for a yearly skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Mr. Daggers presents today for his follow up of his atopic flare-up , which I had seen him last date of service of 04/11/2012. The patient has grew tremendously. He only has some mild residual patches of xerosis on the fingert ips. The patient s mother has accompanied him today and states that he had tolera ted the Prednisone taper as well as Keflex therapy well. The patient is very ex cited with his progress. He continues to use Cetaphil Restoraderm body wash and moisturizer. The patient s mother has switched to free and clear detergent. Ove rall, they are very happy with the progress. OBJECTIVE: Physical examination reveals well-developed, well-nourished young Ca ucasian male accompanied in office by his mother, in no apparent distress. I di d examine today the scalp, face, neck, trunk, and bilateral upper and lower extr emities. Face is clear today as is the trunk, arms, and legs. He does have a pa tch of mild residual hyperpigmentation on the posterior aspect of the right uppe r thigh. Other than that the trunk, arms, and legs have responded extremely wel l to both the Prednisone taper and the continued topical therapy. The hands do continue to have some generalized fine flaking and signs of chronic paronychia c ontinue to exist to include complete loss of cuticle along with a clubbing of na ils, which he has had since he was baby. I have noted the patient has been test ed for cystic fibrosis and has screened negative. He does have a history of ast hma. ASSESSMENT/PLAN: Atopic dermatitis with some postinflammatory hyperpigmentation and generalized xerosis still continuing on the hands. I have given the patien t a prescription today in office for clobetasol spray to be used on the hands tw ice daily as needed for extremely resistant flares. Otherwise, I do not want hi m to use this anywhere else on the body. He will continue on with his regular t opical to the body as well as moisturization two to four times daily. The patie nt s mother states he is good today on all his medications. I have advised her to

feel free to call the refill line should she need refill of any of the topicals or the antihistamines. She will continue on with fragrance free, soaps, and mo isturizers as well as fragrance free detergents. Of note, the patient is going to Cub Scout camp soon. She is concerned about the lack of attention he may rec eive or the lack of attention he may give to his atopic skin (however, the patie nt states that he will be compliant with his regimen. I have advised her to cal l the office if there are any significant flare-ups requiring medical attention) . Follow up at this time will be in two to three months to see how he is respon ding to the medications as well as clobetasol spray for the hands. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\patricia jill samples consolidated\06-06-12\06062012 pjl.doc 7/28/2012 1:0 2:18 PM 108032 SUBJECTIVE: Thamara presents to the office today for suture removal on the vert ex scalp. She is also in for discussion of pathology results. Suture site on t he vertex scalp at today s exam reveals a well-healed well-approximated wound. Th e patient presents for suture removal. Patient has no complaints about the surg ical site, and the wound has healed without any complication. The wound was cle ansed and sutures were removed. The patient was instructed to call me if there is any concern about the surgical site in the future. The patient denies any f ever, sweats, or chills since date of biopsy and denies any abnormal oozing, ble eding, crusting, or drainage at the wound site. I have informed the patient the results have come back consistent with non-scarring alopecia, but differential including telogen effluvium, androgenetic alopecia, and early traction alopecia and alopecia areata cannot be excluded. We have discussed these various etiolog ies. I have consulted also with Dr. Alan Rolfe regarding this patient today in office. He has advised a course of clobetasol topical solution to be applied to the scalp for a cycle of three weeks on, two weeks off, and then repeat one tim e. Follow up will be in approximately two to two and a half months for reevalua tion. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Andrea presents today for followup on her alopecia, not otherwise s pecified. Labs that all have been returned to last date of service 05/14/2012 w as within normal limits with the exception of her vitamin D level, which was low . She is now on vitamin D supplementation per her pediatrician. The patient s mo ther is in today and states that the hair is continuing to fall out and has espe cially noticed when the hair is wet. She does suspect telogen effluvium etiolog y as the patient is stressed to move in the next couple of months. OBJECTIVE: Physical examination reveals a well-developed, well-nourished Caucas ian young female, in no apparent distress. On examination of the scalp, face, n eck, trunk, and bilateral upper extremities, she does have some scattered symmet rical benign appearing nevi light-brown to medium-brown 2-3 mm in diameter wellcircumscribed and evenly pigmented on the arms, neck, and face. She also has no patches of hair loss noted at today s visit, but does appear to have some subject ive thinning since I had initially seen her back in April of 2012. The patient does have some inflammatory acneiform papules present on the face. 1. Alopecia, not otherwise specified, suspect telogen effluvium secondary t o stress. The patient was seen by both myself and Dr. Alan Rolfe today. He has discussed with the patient and her mother that we will do a three-week course o f clobetasol 0.05% solution applied in a cycle of three weeks on and two weeks o ff and then followup at that time. The patient will be discontinuing the DermaSmoothe oil and instead using the clobetasol 0.05% solution over the few weeks a t night. 2. Acne vulgaris, the patient is continuing on with the CeraVe oil control, anti-foaming cleansers, and oil free moisturizers as well as clindamycin 1% lot ion to the affected areas on the face. She is also using Epiduo on the affected areas at night.

3. Benign nevi of the arm. All nevi are well marginated, homogenously pigm ented, symmetrical, benign appearing moles. We reviewed ABCDs of melanoma. The patient will monitor moles for any change or growth. The patient understands i f any of these lesions begin to change, they are to return to clinic for re-eval uation. Follow up will be in approximately four to six weeks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: Physical examination reveals a well-developed, well-nourished Caucas ian female, in no apparent distress. On the area of concern on the upper and lo wer lids, she does have some lichenification with some erythematous patches on b oth the upper and lower lids consistent with chronic ongoing eyelid dermatitis. The patient was evaluated by both myself and Dr. Alan E. Rolfe today. He does believe this looks contact in nature likely allergic contact dermatitis versus i rritant contact dermatitis. ASSESSMENT/PLAN: Dermatitis, not otherwise specified of the eyelids likely ACD versus ICD. Dr. Rolfe was discussed with the patient the patch testing. She ma y be a candidate for patch testing in the future, but she must go off all topica l steroids for at least one to two weeks prior to having the patch test done. T he procedure was explained in detail in office to the patient today. The patien t wishes to defer patch test treatment at this time. Dr. Rolfe has discussed wi th the patient the risks of long-term steroid use in the eye area to include ski n thinning, telangiectasias, and risk for glaucoma or increased pressure behind the eye. We are going to switch to a nonsteroidal Elidel. I have written her f or a 30 g tube. She may apply this up to twice daily as needed for flare-up. I have advised the patient the first few applications may be somewhat tingly when applying. She understands. Also she is to remove any fragranced product s from her household and personal care for a period of four months to see if thi s will help to alleviate the situation as well. She may also wish to try a coup le days of sleeping without the dog to see if that will help out with the situat ion too. Follow up at this point will remain open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Squamous cell carcinoma of the anterior tibial surface of the left lower extremity. The nature and purpose of the procedure, associated risks, and poss ible complications were discussed with the patient. Complications including hem orrhage, infection, scarring, necrosis, dehiscence, and recurrence were reviewed . The surgical site was prepped with alcohol. 1% lidocaine with epinephrine wa s infiltrated for local anesthesia. The clinical margins of the lesion were del ineated. The site was then treated with 3 cycles of electrodesiccation and cure ttage, ensuring all borders and the base were clear of grossly abnormal tissue. The site measured 1.4 cm after the third curettage cycle. The site was dressed with Polysporin and bandaged. The patient tolerated the procedure well without any complications. Would care instructions were reviewed. 2. Lentigo. Ms. Hoffman was reassured that these are benign lesions. They do however, indicate diffuse sun damage. We discussed the importance of wearin g a broad- spectrum sunscreen with an SPF of 30 or greater whenever she is expos ed to the sun. A handout of recommended broad-spectrum sunscreens was given to the patient as well as numerous broad-spectrum sunscreen samples. 3. Xerosis. I discussed the importance of using a very mild soap in the ba th or shower such as Dove for sensitive skin, Cetaphil, or CeraVe. Showers shou ld be with warm or cool water and limited to 5 to 10 minutes. After towel dryin g, the patient should apply a thick emollient cream when the skin is still damp. Cetaphil, Creamy Vaseline, Eucerin, and CeraVe are good moisturizers to use. Another application of moisturizer should be used during the day. Follow up wil l be in four weeks for check of the wound. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ASSESSMENT/PLAN: Lichen simplex chronicus with a couple of early prurigo nodule s. The patient again wishes to do intralesional injection and says that she is happy with the clobetasol topical ointment to be applied to the arms twice daily

as needed for flares. She has used the desonide ointment only when flaring as well. Follow up at this time will be open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Mr. Lancaster presents today for a couple of spots of concern on th e arms and face. The patient has a history of inflammatory acne rosacea of the face with recurrent papule and pustule formation. He also has rhinophyma associ ated with it as well. He does suppress well with doxycycline 50 mg oral therapy q.d. and states he has continued on this medication with good results. OBJECTIVE: On exam, he is a well-developed, well-nourished Caucasian male, Fitz patrick type I, in no apparent distress. I did examine today the scalp, face, n eck, and bilateral upper extremities. Face is being clear of any precancerous o r malignant concerns; however, on the dorsum of the forearms and the hands, he d oes have one hyper keratotic papule on the dorsum of the right hand as well as f ive ill-defined erythematous plaques on the left arm, all six which are consiste nt with actinic keratoses. On the left arm, he also does have a 1.2-cm in diame ter erythematous plaque with scale and induration noted, rule out squamous cell carcinoma versus hypertrophic actinic keratosis versus basal cell carcinoma. Th e patient stated that this has risen somewhat recently. The patient also does h ave some fine flaking consistent with xerosis noted on both forearms. 1. Neoplasm of uncertain on the left arm, rule out SCC versus BCC versus hy pertrophic actinic keratosis. After obtaining written consent, the patient was prepped with alcohol. Buffered Lidocaine with epinephrine 1% was administered f or local anesthesia. The lesion was removed in its entirety via a shave procedu re with a Dermablade. Drysol was used for hemostasis. Polysporin ointment was applied and the wound was bandaged. Wound care instructions were reviewed. The patient tolerated the procedure well. Pathology results will be mailed to the patient. This was done in the office today. 2. Actinic keratoses. Six were treated in the office today, one on the dor sum of the right hand, five on the dorsal aspect of the left forearm with liquid nitrogen cryotherapy x2 cycles. Postprocedure care and expectations were discu ssed with the patient. He tolerated the procedure well. 3. Xerosis. I discussed the importance of using a very mild soap in the ba th or shower such as Dove for sensitive skin, Cetaphil, or CeraVe. Showers shou ld be with warm or cool water and limited to 5 to 10 minutes. After towel dryin g, the patient should apply a thick emollient cream when the skin is still damp. Cetaphil, Creamy Vaseline, Eucerin, and CeraVe are good moisturizers to use. Another application of moisturizer should be used during the day. Of note, the patient is using the doxycycline as well as the MetroGel. He will continue on t his for his rosacea, but I did not want to discuss this because we did not addre ss the rosacea at today s office visit. Follow up will be depending pathology res ults. Otherwise, we will see him back in three months for followup of his rosac ea. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: The patient presents for continued management of her palmar hyperhi drosis. We will be treating both the left and right hand at today s visit. A tot al of 100 units will be injected into each palm. The patient denies pregnancy a t today s visit. OBJECTIVE: The patient is a well-developed, well-nourished Asian-American femal e. She is in no acute distress, alert and oriented. Both hands are moist, cool , and actively perspiring at today s visit. ASSESSMENT/PLAN: Palmar hyperhidrosis. Today under aseptic technique a total o f 100 units were injected into the right hand and 100 units was then injected in to the left hand. The Botox solution was 4 mL of normal saline. The injections were made using the 30-gauge needle of approximately 1 cm apart to assure even distribution of the medications. Post injection instructions were provided and the patient will follow up p.r.n. Anesthetic provided with ice and pressure. L ot number for the Botox today used both vials were lot C3012 C3 both 100-unit vi als, expire October of 2014. I was assisted today by dermatology technician Shi

rley Carpenter. Follow up will be pending breakthrough sweating. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: On exam, she is a well-developed, well-nourished Caucasian female, i n no apparent distress. I did examine the area of concern on the lateral aspect of the right lower leg; there is a well-healed well-approximated wound. The pa tient denies any fevers, sweats, or chills since date of biopsy and no abnormal oozing, bleeding, crusting, or drainage in the region. She also does have on ex amination of the lower extremities some light tan and light brown macules of var ious shapes and sizes consistent with solar lentigo and some generalized fine fl aking of the lower extremities consistent with xerosis. ASSESSMENT/PLAN: Dermatitis, not otherwise specified, results have been come ba ck consistent with lichenoid purpuric dermatitis. This was discussed in office today with the patient. She understands this is a benign condition to which she may use the steroid as needed for flare-ups. She states she is good on refills at this point. Follow up will remain open-ended. Patient presents for suture removal. Patient has no complaint about the surgical site and the wound has hea led without any complication. The wound was cleansed, suture were removed. The patient was instructed to call me if there is any concern about the surgical si te in the future. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: On exam, he is a well-developed, well-nourished African-American mal e, in no apparent distress. I did examine the area of concern today. On the up per lip midline, there is approximately dime-sized areas of hyperpigmentation wi th some hyperkeratotic tissue present. This was viewed in office today by Dr. R olfe under dermoscopy. He does believe this appears verrucous in nature. The p atient has been informed by Dr. Rolfe that as this is verrucous tissue, it will require either cryotherapy or electrodesiccation for treatment. The patient has questioned probably might be able to come to a definitive diagnosis. I have in formed him that this would require biopsy. ASSESSMENT/PLAN: Neoplasm uncertain of the upper lip likely verruca in nature. I have had the patient discuss with his wife the options for treatment. He wis hes to talk to his boss first before he takes off work, as we have informed the patient he may have some difficulty eating along with some associated swelling o f the lip secondary to cryotherapy and some possible blistering. He will follow up as the schedule allows. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: On exam, she is a well-developed, well-nourished African-American fe male, in no apparent distress. She does have some hypertrichosis of the lashes. Of note, the patient has not used Latisse in a quite few months. ASSESSMENT/PLAN: Hypertrichosis of the lashes. Cosmetic consult done today. N o charge for Latisse prescription, which was written, apply with brush one drop to each upper lid lash base at night. A 3 mL bottle with brush kit was written along with three refills. Follow up will be open-ended. I have advised the pat ient we will e-mail her for any promotional rebates. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: Physical examination reveals a well-developed, well-nourished Hispan ic-American female, in no apparent distress. I did examine today the areas of c oncern. On the anterior chest and cleavage region, she does have some warty wax stuck-on appearing papules consistent with seborrheic keratoses. She also does have some fleshy pedunculated growths, flesh-colored to medium brown in nature consistent with skin tag, two on the left neck and two on the right upper back, all four which lay directly in the bra line and necklace line. She also points to an additional concern on the right buttock near the gluteal cleft, there is a 1 cm nonfluctuant nodule consistent with epidermal inclusion cyst. The patient says this is visible through her when she wears loose pants and she would like to get this taken care of as soon as possible via surgical excision.

1. Epidermal inclusion cyst, right buttock near the gluteal cleft. I have set up a 30-minute excision with Dr. Rolfe and Ms. Jusino for surgical excision of this cyst given the region. He has done a mini consult in the office with th e patient today. 2. Skin tag. Four tags that were traumatized at the base and irritated wer e removed for the patient today in office under aseptic technique. The site was marked and confirmed with the patient, cleansed with alcohol, and infiltrated w ith lidocaine 1% with epinephrine, 1:100,000 dilution as local anesthesia. The skin tags were then removed via surgical scissor snip procedure. The patient to lerated the procedure well. Wound care was discussed with the patient as well a s postprocedural care and expectation. She understands. 3. Seborrheic keratosis. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. Follow up will be for surgical removal of her cyst with Dr. Alan Rolfe. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: On exam, he is a well-developed, well-nourished young Hispanic-Ameri can male in no apparent distress. I did examine the area of concern today to in clude the face, neck, chest, and back as well as upper extremities. On examinat ion of the face, he does have some inflammatory papules and pustules most notabl y in the bilateral malar cheek region and perinasal region consistent with acne vulgaris. He also does have some hyperkeratotic plugging on the back with some postinflammatory erythema, which looks to be consistent with keratosis pilaris, but cannot completely rule out an element of seborrhea in the form of yeast foll iculitis and even possibly some seborrheic dermatitis given the distribution of the acneiform papules on the face. The patient s mother denies any family history of rosacea or seborrheic dermatitis, but I will keep that in mind after we eval uate at two months whether or not the acne treatment I am prescribing today has been effective or not. 1. Acne vulgaris with postinflammatory changes. I am going to start the patien t on triple therapy regimen to include the following, Cetaphil DermaControl wash and moisturizer to be used both day and night. Also in the morning after washi ng he will apply a thin film of Acanya one pump to the face spread sparingly. H e will also take Doryx 150 mg tablet. Side effects of the Acanya and the Doryx were discussed with the patient in office today. He understands. At night, he will then put a small pea-sized amount of Epiduo gel on to the face and spread i nto a thin film. He will start this Monday and Friday titrating up to every oth er night or nightly use as tolerated. Side effects of the topical retinoid ther apy were discussed with the patient and reviewed. He understands. 2. Keratosis pilaris. I have informed the patient on the benign nature of this condition. No treatment is necessary at this time. Reevaluation in two months . If he continues to have some persistent erythema either on the face or the ba ck, he may wish to do a trial of ketoconazole shampoo used as skin soaking solut ion. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ASSESSMENT/PLAN: Allergic contact dermatitis with xerosis, moderate-to-severe b reakout in nature. The patient was seen by both myself and Dr. Alan Rolfe today . We have explained to the patient the risk of intralesional high potency Kenal og injection to include avascular necrosis. Instead today Dr. Rolfe has advised continuing on the prednisone taper for 15 more days. She is to take 15 mg per day for the first three days tapering down to 40 mg for days four through six, t apering down to 30 mg for days seven though nine, tapering down to 20 mg days 10 through 12, and tapering down to 10 mg days 13 through 15. A total of 45 table ts were given to the patient with no refill. Additionally, we are going to have her discontinue the fluocinonide cream and instead give her the highest potency topical steroid available, which is clobetasol ointment 0.05%. She is to apply this to affected regions as needed twice daily. Side effects of the topical st eroids and the oral steroids were discussed with the patient in office today. S he does understand and she understands she is not to use this on the face or any

delicate skin or body fold areas (the clobetasol). At this point, follow up will be open-ended. If she does not improve over the n ext week then we would like to see her back. I have advised the patient to comp lete the course of cephalexin and I have encourage her to take the Atarax that w as prescribed for her at Patient First as needed for itching, as she has stated that that has helped with the itch relief somewhat. Follow up open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Brianna presents to the office for what she thinks is allergic reac tion to either her topical acne medicine or her Doryx. She states that she deve loped a very sensitive red itchy reaction on the neck even though she has been u sing the Differin on the chest and back, not on the neck. She also states that she has removed benzoyl peroxide from her regimen. However, the patient s mother has informed me that while she has discontinued the Epiduo and is using only the Differin gel, which does not have benzoyl peroxide in it, she has continued to use the Proactiv line, which I have informed the patient and her mother does als o have benzoyl peroxide in it. OBJECTIVE: The patient is a well-developed, well-nourished Caucasian female in no acute distress. She does have some persistent inflammatory papules present o n the forehead and perinasal and bilateral malar cheek region. Scattered across the back, shoulders, and chest she does have a few scattered inflammatory papul es as well. On the submental/neck region, the patient does have some well-demar cated erythema with some flaking and this does appear to be possibly fungal in n ature. ASSESSMENT/PLAN: Irritant reaction possibly from continued use of benzoyl perox ide, but may also present as fungal or yeast as well. KOH was done showing yeas t on the microscopic exam. I have given the patient a large tube of ketoconazol e cream, which I would like for her to use twice daily for approximately one wee k pass clearing. That diagnosis is dermatitis not otherwise specified. Also we are going to have the patient discontinue her Proactiv as it does contain benzo yl peroxide and instead I have given her the Cetaphil DermaControl line of washe s and moisturizers and said it should be gentler on her skin. The patient is fe arful that the Differin is the culprit of this rash, Dr. Rolfe has advised her t o do a small patch test on the arm apply twice daily over a period of 48 hours t o see if she develops any type of irritant reaction. If no reaction is elicited in 48 hours, then the patient can rest assured that it is not the Differin caus ing this. If it is in fact not the Differin and she wishes to continue on with topical Differin therapy, which I have encouraged, I would like for her to start out slowly using the Differin every third night to start titrating up to nightl y use or every other night use only as tolerated. The patient is going to disco ntinue Doryx as well over the next week, as she is getting ready to go on a crui se. She will be resuming the Doryx, however, when she comes back. Dr. Rolfe ha s discussed with the mother and the patient in office today. He does not believ e that this is related to the Doryx and it does not appear to be a drug reaction as it would often be more generalized. Follow up will be in approximately two to three months. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Tara presents to the office today for suture removal on the anterio r aspect of the left thigh. Pathology results are consistent with benign intrad ermal nevi. This was discussed with the patient in office today. OBJECTIVE: On examination, she is a well-developed, well-nourished Caucasian fe male in no apparent distress. The suture site on the anterior aspect of the lef t thigh is well-healed, well-approximated. The patient denies any fever, sweats , or chills since the date of biopsy and no abnormal oozing, bleeding, crusting, or drainage from the wound site. Patient presents for suture removal. Patient has no complaint about the surgical site and the wound has healed without any c omplication. The wound was cleansed, suture were removed. The patient was inst ructed to call me if there is any concern about the surgical site in the future. Follow up will be in one year for a total skin exam.

The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Rogelio presents to the office today for a 48-hour acute patch test read. The patient states no noted areas of irritation on the back, but states he is still continuing to itch on the arms and legs. The patient is currently u sing Cetaphil soap and cream as well as Arm & Hammer detergent. The patient s wif e who has accompanied him today states that it does contain a scent. I have adv ised switching to all free and clear and we will give samples to them today upon their departure. They are also using Eucerin anti-itch cream. OBJECTIVE: He is a well-developed, well-nourished Filipino male, in no apparent distress. The patient was lead to the examining table and the panels were remo ved. He was then left to sit for 15 minutes. Upon reading the panels, he did h ave some scaliness and xerosis noted on the number 6 (fragrance contact allergen ). I do not believe that this would even be graded as 1+ reaction. However, it does have some mild erythema. No induration is noted. No vesiculation. The Q uaternium-15 contact allergen #18 showing some erythema with slight induration. These are the only two where any type of reaction is noted at today s visit. I h ave talked with the patient regarding followup. He has advised me that they are following up Monday for the delayed read. They will be following up with physi cian Dr. Rolfe. Treatment plan will be tailored at that time. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: The patient is a well-developed, well-nourished Caucasian female in no acute distress. On examination, she does have some mild erythema noted on th e upper eyelids bilaterally. No edema is noted at today s visit. ASSESSMENT/PLAN: Eyelid dermatitis likely secondary to contact in nature from w orking outside during the weekend. I am going to have the patient use FML ophth almic suspension 0.1%. She will apply one drop to each eyelid once or twice dai ly over the next week to two weeks. If it does not improve in two weeks, I woul d like for her to follow up back to the office. Etiology of eyelid dermatitis w as discussed with the patient. I have explained to her that this is likely due t o contact with something that was on the fingertips. This could be likely secon dary to plant resins while working in the garden, etc. Follow up at this point will remain open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Verrucae. These were removed today in office under aseptic technique. The site was marked and confirmed with the patient, cleansed with alcohol, and infil trated with lidocaine 1% with epinephrine, 1:100,000 dilution as local anesthesi a. A #15-blade was then used to debulk and remove the three verrucae. They wer e not sent off to the pathology. Drysol was used for hemostasis. The patient t olerated the procedure well. Wound care was discussed with the patient and her father, both voiced understanding. 2. Lentigines. Ms Peirce was reassured that these are benign lesions. They do however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF of 30 or greater whenever she is exposed to the sun. A handout of recommended broad-spectrum sunscreens was given to the patient as well as numerous broad-spectrum sunscreen samples. Follow up will b e open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ASSESSMENT/PLAN: Seborrheic dermatitis with xerosis. We will continue on with the ketoconazole shampoo two to three times weekly. Also, she will use the deso nide cream to the face twice daily only as needed for flares. For the itchy sca lp, I have advised the patient to continue on with the shampoo two to three time s during the weekdays and then use the clobetasol foam weekend use only. Follow up will be open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Nancy presents to the office today for suture removal on the left f

orearm. The patient denies any fever, sweats, or chills since the date of biops y, nor any abnormal oozing, bleeding, crusting, or drainage from the wound. Pat ient presents for suture removal. Patient has no complaint about the surgical s ite and the wound has healed without any complication. The wound was cleansed, suture were removed. The patient was instructed to call me if there is any conc ern about the surgical site in the future. This was done in office today by She lly Carpenter, DT. Dr. Rolfe and I have discussed with the patient her patholog y results in office today, which are consistent with superficial dermal fibrosis . Dr. Rolfe believes this is most likely related to her lupus. He has advised that the patient may opt to come in for intralesional injection of a low strengt h steroid into the area for flattening and softening of the region; otherwise, t here is not much else that needs to be done with regards to treatment of the are a. The patient is on Plaquenil and is being seen by a rheumatologist for system ic lupus at this time. Follow up will be in approximately three weeks, which wi ll allow time for the wound to heal prior to having the intralesional injection. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: Physical examination reveals well-developed, well-nourished Caucasia n female in no apparent distress. I examined today the face, neck check back, a nd bilateral upper extremities as well as abdomen. On the chest today, she does have some warty waxy stuck-on appearing papules consistent with seborrheic kera tosis. She also has some scattered lentigines on the sun exposed areas of the u pper body, light tan, light brown in nature in various shapes and sizes. There are also too numerous to count symmetrical cherry red papules on the trunk consi stent with cherry hemangioma and some fleshy pedunculated growth around the neck line and color consistent with skin tags, which the patient states do not bothe r her. She states they are not touched or traumatized in anyway. She does have a spongiotic appearing patch present on the left hip, which looks to be consist ent with allergic contact dermatitis secondary to poison ivy. 1. Allergic contact dermatitis secondary to poison ivy. I have given the patie nt a prescription for clobetasol ointment. I would like for her to apply this t wice daily to the affected areas of skin until clear. I have advised the patien t if it does not clear over the next week to two weeks, I would like to see her back. 2. Lentigo. Ms Philips was reassured that these are benign lesions. They do h owever, indicate diffuse sun damage. We discussed the importance of wearing a b road- spectrum sunscreen with an SPF of 30 or greater whenever she is exposed to the sun. A handout of recommended broad-spectrum sunscreens was given to the p atient as well as numerous broad-spectrum sunscreen samples. 3. Seborrheic keratosis. The patient was informed of the benign nature of thes e lesions and no treatment is necessary at this time. 4. Skin tags. The patient was informed of the benign nature of these lesions a nd no treatment is necessary at this time. 5. Hemangioma. The benign nature of the lesions was discussed and no treatment is necessary at this time. Follow up will be anywhere from 1-2 years for her n ext total skin exam given the patient s low risk profile. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ASSESSMENT/PLAN: Acne vulgaris with some postinflammatory changes and xerosis. The patient will continue CeraVe Foaming Face Wash to use q.a.m. and q.p.m. Sh e will also continue on the Benzamycin q.a.m. and minocycline 50 mg tablets one tab p.o. b.i.d. for the next two months. The tretinoin cream she will also cont inue with nightly. After two months, we will reevaluate. I have advised the pa tient we may opt to do reduction in the dose to the minocycline down to possible Solodyn 45 mg tablet for trial of two months and if the patient does not experi ence any breakthrough flares, we may wish to discontinue the minocycline entirel y after a two-month trial of the reduced dose of the Solodyn 45 mg. Follow up a t this point will be in two months. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment.

SUBJECTIVE: Shelby presents to the office today for her initial treatment of Bo tox for hyperhidrosis in the axillary region. The patient denies pregnancy at t oday s office visit. A 100 unit vial has been approved and is going to be injecte d into 50 units into the left axillary vault, 50 units into the right axillary v ault today, lot #C3017 C3F, expiration date October 2014. ASSESSMENT/PLAN: Axillary Botox for hyperhidrosis. Under aseptic technique, 10 0 units was injected today, 50 units into the left axillary vault, 50 units into the right axillary vault after performing a starch iodine test. The patient to lerated the procedure well. The risks and benefits of treatment were discussed. Risks of treatment include a vasovagal response, (including flushing, faint fe eling, sweating and nausea/vomiting), brow droop or eyelid ptosis, headache and bruising. Corrective effects (decreased movement) are usually noticed 3 days af ter treatment. The full effect of treatment is seen at 1-3 weeks. The patient was instructed not to lay down or bend forward for prolonged periods during the first few hours after treatment to avoid the risk of drug migration. A copy of the FDA Medication Guide regarding potential risks was provided. Specifically, the risks of potential severe neurologic effects were discussed. However, we st ressed that these effects have not been reported with the appropriate dosing/adm inistration of Cosmetic Botox or it s use for hyperhidrosis. I have advised the p atient followup will be pending breakthrough sweating. The patient voiced under standing. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\patricia jill samples consolidated\06-07-12\060712_pjl.doc 7/28/2012 1:02: 21 PM 139264 SUBJECTIVE: Mr. Morris presents to the office today for suture removal on the c entral chest. The patient denies any fevers, sweats, or chills or any abnormal oozing, bleeding, crusting, or drainage from the wound site. OBJECTIVE: On exam, he is well-developed, well-nourished Caucasian male with am putation of the right leg. He is in no apparent distress. Alert and oriented. Wound site on the central chest is well healed and well approximated. The pati ent presents for suture removal. Patient has no complaints about the surgical s ite, and the wound has healed without any complication. The wound was cleansed and sutures were removed. The patient was instructed to call me if there is an y concern about the surgical site in the future. Pathology results were discuss ed with the patient consistent with epidermal inclusion cyst. I have informed t he patient this is a benign condition. No further treatment is necessary. Foll ow up is open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ASSESSMENT/PLAN: Allergic contact dermatitis, resolved. Also, generalized xero sis being treated with clobetasol solution as needed for flares. The patient st ates she is good on refills. I have advised her to call in should she need them . Otherwise, follow-up with me in September of 2012 for her annual skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ASSESSMENT/PLAN: Cosmetic Botox glabellar region, lot number for Botox today is C29196 C2, expiration date May 2013. Approximately 27 units were injected into the glabellar region today, 8 units into the procerus, 9 units into the right c orrugator at two injection points, 10 into the left corrugator at two injection points at a cost of $260 for the upper forehead region. Side effects and expect ations were discussed for cosmetic Botox. The patient was informed not to lie d own for a period of four hours post procedure. She tolerated the procedure well with minimal bleeding and bruising. Botox consent form is on file for the pati ent. We will see Shahid back as needed basis for followup. Additionally, she h as inquired into hydroquinone for lightening up of the facial lentigo which she has. I have given her some samples of the Aclaro hydrocodone 4% for her to try. Follow up open-ended.

The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Ms. Girard was sent in to us today. She was told by her plastic su rgeon that she had growth in the nose, he was concerned about being cancerous. Her plastic surgeon is Dr. Ted Uroskie. She is being treated for breast reconst ruction. She is a breast cancer survivor. The patient has used Efudex in the p ast on her skin with a permanent reaction noted and good results. She is curren tly taking Arimidex 1 mg and Zocor 20 mg. FAMILY HISTORY: The patient denies any personal history of skin cancer. She de nies any family history of skin cancer. She does admit to blistering burns as a child and to tanning bed use more than 20 times in her life. OBJECTIVE: Physical examination reveals a well-developed well-nourished Caucasi an female, in no apparent distress. I did examine the total body to include the scalp, face, neck, trunk and bilateral upper and lower extremities including bu ttocks region. On the face, she does have some erythema on the bilateral malar cheek region and on the perinasal region with some telangiectasias, which looks to be in the distribution pattern of rosacea, but the patient denies any persona l or family history of rosacea. She does have on the right nasal tip an erythem atous papule suspicious for basal cell carcinoma versus sebaceous hyperplasia ve rsus papular rosacea. On examination of the sun exposed areas of the face, the patient does have some well-defined waxy erythematous plaques, three on the left side of the face and one on the right nasal bridge consistent with actinic kera tosis. Also on the sun exposed areas of the face, neck, chest, and upper and lo wer body she does have numerous light-tan light-brown macules of various shapes and sizes consistent with solar lentigos as well as some flesh colored to medium brown colored _____ waxy stuck-on appearing papules and plaques consistent with seborrheic keratoses. Physical examination of the upper and lower extremities reveals some generalized fine flaking of the lower extremities consistent with x erosis. She also has some well defined waxy erythematous plaques, one on the ri ght leg and two on the left leg consistent with actinic keratosis. She also has six present on the dorsum of the right forearm, four present on the dorsum of t he left forearm also consistent with actinic keratosis. On examination of the s calp, there is some inflammation and fine flaking noted on the base of the scalp consistent with xerosis. She also has some spider telangiectasias of the bilat eral lower extremities. 1. Telangiectasias of the face and also spider telangiectasias of the lower leg s bilaterally. For treatment of the telangiectasias, I have advised the patient this is a cosmetic procedure. I am happy to give her the name and information for Dr. Lawrence Chang should she desire treatment in the future. 2. Neoplasm, uncertain, of the nasal tip. Rule out BCC versus sebaceous hyperp lasia versus papular rosacea. The proposed procedure, alternatives, risks, and benefits were discussed with the patient. Under 1% lidocaine with epinephrine a nesthesia, using a #15 scalpel blade, shave biopsy was performed. Tissue submitt ed for histopathology. A dry dressing with Polysporin was applied and wound car e instructions given. Pathology results will be mailed to the patient. Further treatment based on histopathology. 3. Xerosis of the scalp with significant itching. I have given the patient a p rescription for clobetasol solution for the scalp which she is to apply at night and rinse out in the morning p.r.n. flares. I have written for a large bottle with one refill. 6. Lentigo. Ms Girard was reassured regarding the benign nature of these lesio ns. These lesions do, however, indicate diffuse sun damage. We discussed the i mportance of wearing a broad- spectrum sunscreen with an SPF of 30 or greater wh enever she is exposed to the sun. A handout of recommended broad-spectrum sunsc reens was given to the patient as well as numerous broad-spectrum sunscreen samp les. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Robyn presents to the office today for an area of concern on the ri ght nasal bridge which she had treated with liquid nitrogen cryotherapy at last

date of service 04/05/2012. She stated that it did heal up; however, it has bee n continuously rubbed by the glasses and has started bleeding once again. The p atient has a history of DSAP treated currently with Dovonex ointment successfull y. 1. Actinic keratosis. Seven were treated in office today with liquid nitrogen cryotherapy x2 cycles. Postprocedural care and expectations were discussed to t he patient, she understands. 3. Lentigo. Ms Moseley was reassured regarding the benign nature of these lesi ons. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF of 30 or greater w henever she is exposed to the sun. A handout of recommended broad-spectrum suns creens was given to the patient as well as numerous broad-spectrum sunscreen sam ples. 5. Neoplasm, uncertain, nasal bridge. Rule out resistant AK versus SBCC. The patient states that she is taking a test tomorrow and as the location is right u nder the glass pads she would like to have that biopsy done in approximately fou r weeks. We have scheduled an appointment for biopsy second week in September a nd we will at that time do a biopsy of the right nasal bridge once gain ruling o ut actinic keratosis versus SBCC. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ASSESSMENT/PLAN: Alopecia areata with intralesional injection done at today s vi sit. Final series of injections will be done today. Under aseptic technique ap proximately 2.0 cc of Kenalog 4 mg/cc was injected into the areas of alopecia in a series of approximately 8 injections. Postprocedural care and expectations w ere discussed with the patient. He tolerated the procedure well. I advised the patient that followup at this point will be open-ended and that complete hair g rowth can take anywhere from one to three years for it to totally grow back in. The patient voiced understanding. Followup is open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Neoplasm, uncertain, right forehead. Rule out BCC versus SCC. The proposed procedure, alternatives, risks, and benefits were discussed with the patient. U nder 1% lidocaine with epinephrine anesthesia, using a #15 scalpel blade, shave biopsy was performed. Tissue submitted for histopathology. A dry dressing with Polysporin was applied and wound care instructions given. Pathology results wi ll be mailed to the patient. Further treatment based on histopathology. 2. Actinic keratoses. Four were treated in office today with liquid nitrogen c ryotherapy x2 cycles. Postprocedural care and expectations were discussed with the patient. He tolerated the procedure well. 3. Lentigo. Mr. Wilkins was reassured that these are benign lesions. They do however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF of 30 or greater whenever he is exposed to the sun. A handout of recommended broad-spectrum sunscreens was given to the p atient as well as numerous broad-spectrum sunscreen samples. 6. Skin tag. The patient was informed of the benign nature of these lesions an d no treatment is necessary at this time. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ASSESSMENT/PLAN: Acne vulgaris with some postinflammatory changes, some older r esolving lesions and some milia-like cysts on the chin crease and jaw line. He is going to continue the minocycline 100 mg tablets 1 p.o. q.d. over the next fe w months. The patient states he is good on refills today. I have advised him t o call in as needed for refills. He voiced understanding. He will also continu e with CeraVe foaming face washes and CeraVe AM and PM moisturizers and a pea-si zed amount of Tazorac 0.1% gel at night to the face. Further back, I have writt en him for 100 g can of BenzEFoam 9.8% Ultra and given him applicator as well as a sample. He is to apply those to dry skin before entering shower. Leave it o

n the dry skin for two minutes and then enter shower and rinse off. Distributor s instructions were enclosed with the Back Applicator and were given to the patie nt in office today. I have also explained this to his mother as well at today s v isit and she voiced understanding too. Follow up will be in approximately six m onths. Of note, the patient s mother has stated that Patrick and herself are goin g on a camping trip where he will be exposed to poison ivy and she states he is moderately allergic to the plant. I have given them a couple of sample tubes of Topicort ointment to apply should early signs of the rash present itself while camping. I have advised the patient s mother, however, to follow up if he does de velop the rash once they return home. The patient s mother voiced understanding. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: Physical examination reveals well-developed, well-nourished Caucasia n female, in no apparent distress. I did examine the scalp, face, and neck as w ell as the upper back at today s visit. The patient has too numerous to count len tigines, _____ scattered about the sun exposed areas of the face, neck, trunk, a nd bilateral upper extremities. They are various shapes and sizes. She also ha s on examination of the scalp some fine flaking and a couple of patchy areas of erythema, which look to be consistent with some seborrheic dermatitis or possibl e eczema of the scalp. On the base of the neck, she does have a 2-mm fleshy ped unculated growth consistent with skin tag, which is irritated constantly by her jewelry. On examination of the dorsum of the right great toe, she does have spo ngiotic appearing patch, which looks to be consistent with irritant contact derm atitis, but cannot rule out. A fungal culture will be run today, so that we may be able to rule out fungal entity. 1. Dermatitis, not otherwise specified, right great toe. Fungal culture was se nt today in office by dermatology assistant Ammie Vance. I have also given the patient some samples of Topicort 0.25% ointment to use twice daily to the area a nd if it does not improve in two weeks, then I would like her to return to the o ffice. At two weeks, we will also have the fungal culture samples. If it is po sitive for fungus, we will retail a treatment plan at that time. 2. Seborrhoic dermatitis. I have given the patient a prescription for ketocona zole 2% shampoo. I would like for her to use this once daily over the next two weeks, applied to wet scalp, massage and leave on for 5 minutes and rinse, then go down to twice weekly use after her daily regimen of two weeks. For itchy res istant areas, I would like her to use clobetasol foam to the affected area of th e scalp at night and then rinse off in the a.m. using only as needed for flares. The side effects of the medications were discussed with the patient. She voic ed understanding. I have advised her when she does get pregnant she will need t o discontinue all of these medications as they are indicated class C in pregnanc y. The patient voiced understanding. This includes the Topicort, clobetasol fo am, and ketoconazole shampoo. 3. Skin tag, base of the neck. This was frozen as a courtesy to the patient wi th liquid nitrogen and cryotherapy x2 cycles. Postprocedure care and expectatio ns were discussed with the patient. She tolerated the procedure well. Follow u p will be open ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Actinic keratoses, 10 were treated today in office two on the right arm, two on the left arm, two on the neck, two on the anterior chest, and two on the rig ht cheek and two on the left cheek with liquid nitrogen cryotherapy x2 cycles. Postprocedure care and expectations were discussed with the patient. She tolera ted the procedure well. 2. Xerosis of the face with likely seborrheic component. I have given the pati ent a prescription for desonide lotion 0.05%, I would like for her to use this o nce or twice daily on the face for flares up with dryness. _____ no refills. 3. Lentigo. The patient was reassured regarding the benign nature of these les ions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whe never they are exposed to the sun.

4. Seborrheic keratoses. The patient was informed of the benign nature of thes e lesions and no treatment is necessary at this time. Follow up will be in thre e months to reassess. I have advised the patient to give the desonide a two-wee k trial for the dryness on the face and if she does respond to that I would like for her to use it again two weeks prior to the appointment and at that time, we will reassess any textural changes of the face and determine if there are any p recancerous spots that need treatment at that time. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Stasis dermatitis with xerosis. We will continue on the triamcinolone 0.1% ointment to be applied twice daily only as needed for flares. Side effects of t opical steroids were discussed with both the patient and his wife, who accompani ed him in the office today. They both understand. 2. Lentigo. The patient was reassured regarding the benign nature of these les ions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whe never they are exposed to the sun. Follow up is open ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Cassandra presents to the office today for followup of an area on t he chin, which was seen at last date of service 05/24/2012 by both myself and Dr . David Pariser. He had advised a trial of desonide ointment twice daily to the area. While the patient states that the redness around it has calm down so muc h, she states that it has still not resolved. The patient gives a past history of acne in the past. She states that while she was on amoxicillin therapy for s omething unrelated that it had started to improve; however, now she states she f eels it is worsening again and would like reevaluation. OBJECTIVE: Physical examination reveals a well-developed, well-nourished Caucas ian female, in no apparent distress. On examination of the chin today, she does have an area of inflammation present with central hemorrhagic crust, which is s lightly irritating to the patient along with some fine flaking consistent with x erosis. She does have some scattered lentigines present on the face as well and some generalized fine flaking on the face consistent with xerosis. 1. Neoplasm uncertain, possible inflamed acneiform cyst versus ruptured hair fo llicle. As it is continuing to not heal, I am going to start the patient on dox ycycline 100 mg capsules to take one tab p.o. b.i.d. over the next three weeks. The patient denies any past history of allergies to tetracycline. 2. Lentigo. The patient was reassured regarding the benign nature of these les ions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whe never they are exposed to the sun. Given that the patient has met with the physician assistant for the last two vis its, I have recommended a follow-up visit with the staff physician for her follo wup. This will be in approximately three weeks to reassess. If at that time, t he doxycycline has not helped to clear up the area on the chin, we may consider biopsy at that point. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Sherrie presents to the office today for followup of two areas that were biopsied at last date of service on 05/25/2012. Pathology results have sh owed one on the glabella is consistent with basal cell carcinoma and the area on the left lower leg is consistent with superficial basal cell carcinoma. The pa tient is in today for suture removal. She denies any fever, sweats or chills __ ____ biopsy and denies any abnormal oozing, bleeding, crusting and drainage from the wound. However, she is concerned about the look of the wound on the left l ower leg. She was given Keflex for 7-day period and states that she has not not iced any streaking or abnormal oozing or drainage over the last week. She would simply like an opinion on whether or not it is infected. OBJECTIVE: Physical examination reveals a well-developed, well-nourished Caucas ian female, in no apparent distress. Sutures were removed. The wound is well h

ealed and well approximated in the glabellar region. Follow up will be made for Mohs surgery with Dr. Chang for the biopsy-proven basal cell carcinoma on the g labellar region. For the area on the left lower leg, I have discussed with the patient that this is superficial basal cell carcinoma in nature. I would like t o give this area an opportunity to heal and then we will have her come in to rea ssess the area once the scab has fallen off in approximately 10 weeks. I have w ritten the patient for Biafine emulsion to be applied to the wound twice daily o ver the next couple of weeks or so and I have given three additional days of Kef lex to take three times daily which will get her through the weekend. I have ad vised the patient if she notes any abnormal signs to include streaking, fever, s weats, or chills to immediately call the office, otherwise, her follow up will b e scheduled with Dr. Chang for Mohs surgery of the glabellar region on the 18th of June and her follow up with this office will be in approximately 10 weeks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Acne vulgaris with postinflammatory changes. Continuing on with Duac us e q.a.m., and Differin use q.h.s. For the dermatitis not otherwise specified, a topic distribution in nature of her atopic dermatitis, I have given the patient 60 g tube of triamcinolone 0.1% cream with one refill to be applied twice daily as needed only when itching/flaring. The patient voiced understanding. Side ef fects of the topical steroid were reviewed in the office today. She voiced unde rstanding. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Dermatitis, not otherwise specified. 4 punch was done of the left dorsu m of the left arm. Rule out eruption versus atopic dermatitis versus ACD versus ICD. After obtaining written consent, the patient was prepped with alcohol. Bu ffered lidocaine with epinephrine 1% was administered for local anesthesia. The specimen was obtained with a 4 mm punch biopsy. 4-0 nylon suture was placed. Drysol was used for hemostasis. Polysporin ointment was applied and the wound w as bandaged. Wound care instructions were reviewed. The patient tolerated the procedure well. Pathology results will be mailed to the patient. 2. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. Of note, the patient has been using Dove soap and then using alcohol on the area I have advised the patient to discontinue the use of as he states it soothes it. alcohol as it can be highly irritating to the skin and instead use emollient mo isturizer or one with menthol in it to help with itch relief such as Sarna, whic h he may keep in the refrigerator. Current medications were reviewed with the patient in the office today. The pat ient states he does have no known drug allergies. Additionally, a herpes Zostav ax shingles vaccine was written for the patient today in the office for him to f ill at his local Walgreen s Pharmacy. Follow up will be open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Mr. Dean presents today accompanied by his father for conclusion of his Accutane therapy. He has done six complete months. The patient denies any headaches or vision problems. No GI upset. No myalgias. No arthralgias. No mood swings. No depression, no suicidal ideations. He does have some continued xerosis of the face and lips along with some post-inflammatory erythema. I hav e explained to the patient that postinflammatory erythema may persist for three to five months and the xerosis will likely persist anywhere from two to four mon ths as well. I have given the patient prescription for 45 g pump of Epiduo gel along with co-pay coupon and samples, which he is taking home today. I have als o given him some Aquaphor for the dryness. ASSESSMENT/PLAN: Acne vulgaris with postinflammatory hyperpigmentation and xero sis. Epiduo was given for a spot treatment as well as Aquaphor for the dryness. Follow up at this point with the patient will remain open-ended.

The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: LaTona presents to the office today for followup of her hyperhidros is and her Accutane. The patient has been noncompliant and states that she has gone off the clonidine and Robinul medications. She also states that she had is sues with insurance coverage with regards to the Accutane. She is in today want ing to restart both the Accutane and the clonidine. 1. Acne vulgaris with postinflammatory hyperpigmentation. The patient stat es she is going to get her labs done to include fasting lipid panel and AST, ALT as well as serum HCG done at _____ labs. This is a patient who did have a comp lete hysterectomy. Of note, we will no longer need to do serum HCG in the futur e given this information. I have written her for Accutane 40 mg tablets to take one tablet p.o. b.i.d. for 30 days, written for 60 with no refill. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Ms. McIntyre presents today, a patient of Dr. Baher Basta. The pat ient presents having tried and failed a couple of different antibiotic therapies secondary to infection of a biopsy done by myself at date of service 05/24/2012 . She was seen by Deborah Quinn, nurse practitioner on 05/29/2012 where Deborah had given her Keflex and had done a bacterial culture at that time. The patien t states she was on the Keflex for five days with no problems and at that time s he developed some eye edema. She was then switched by Dr. Basta to Levaquin whi ch she states had caused dizziness and nausea. Finally, she has just recently b een put on Z-PAK by Dr. Karen Rush for one week period of time. She is currentl y on day two and states she is tolerating it well. Her allergies now include su lfa, Levaquin, and Keflex. She seems to be tolerating the azithromycin nicely. OBJECTIVE: On examination today of the right calf, there is a well-healed, well -approximated wound. No secondary infection appears to present at today visit. Bacterial culture results have been returned from LabCorp, date of draw 05/29/2 012, showing aerobic bacterial culture with no growth, that is the final report. With regards to pathology results on the right upper arm, pathology results ha ve come back consistent with dermatofibroma, which is a benign lesion. On her r ight calf, the pathology results have come back as a compound nevus. I have adv ised the patient that neither one of these are malignant and both are benign ent ities and I have also advised her that her bacterial culture shows no growth. I have advised her to continue the course of her azithromycin. We will see the p atient back in one month for a wound check follow up at the patient s request; oth erwise, followup will be in May 2013 for her next annual skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Ms. McIntyre presents today, a patient of Dr. Baher Basta. The pat ient presents having tried and failed a couple of different antibiotic therapies secondary to infection of a biopsy done by myself at date of service 05/24/2012 . She was seen by Deborah Quinn, nurse practitioner on 05/29/2012 where Deborah had given her Keflex and had done a bacterial culture at that time. The patien t states she was on the Keflex for five days with no problems and at that time s he developed some eye edema. She was then switched by Dr. Basta to Levaquin whi ch she states had caused dizziness and nausea. Finally, she has just recently b een put on Z-PAK by Dr. Karen Rush for one week period of time. She is currentl y on day two and states she is tolerating it well. Her allergies now include su lfa, Levaquin, and Keflex. She seems to be tolerating the azithromycin nicely. OBJECTIVE: On examination today of the right calf, there is a well-healed, well -approximated wound. No secondary infection appears to present at today visit. Bacterial culture results have been returned from LabCorp, date of draw 05/29/2 012, showing aerobic bacterial culture with no growth, that is the final report. With regards to pathology results on the right upper arm, pathology results ha ve come back consistent with dermatofibroma, which is a benign lesion. On her r ight calf, the pathology results have come back as a compound nevus. I have adv ised the patient that neither one of these are malignant and both are benign ent ities and I have also advised her that her bacterial culture shows no growth. I

have advised her to continue the course of her azithromycin. We will see the p atient back in one month for a wound check follow up at the patient s request; oth erwise, followup will be in May 2013 for her next annual skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\patricia jill samples consolidated\06-11-12\061112_pjl.doc 7/28/2012 1:02: 22 PM 167936 1. Dermatitis, not otherwise specified, of the left foot likely tinea pedis in nature. Fungal culture was sent today in office by dermatology assistant Nicole Martin. I have given the patient econazole 95 gram tube. She is to apply it t o the affected area of the foot once daily over the next three to four weeks. 2. Nail disease, likely onychomycosis in nature. The patient wishes to defer o ral Lamisil treatment at this time and will initiate white vinegar soaks 20 minu tes a day for the next three months to see if that helps at all. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 3. Seborrheic keratosis. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. 5. History of basal cell carcinoma. We discussed monthly skin checks, look ing for any new or changing pigmented lesions. We also asked the patient to loo k for an irregular border, asymmetry, change in color or increase in diameter of any pigmented lesion. Today I reviewed sun protection guidelines. I discussed ABCD s and the use of sunscreen. I also recommended monthly self skin exam. The pa tient understands we should be notified for any changing lesions, new, or concer ning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ASSESSMENT/PLAN: Acne vulgaris/acneiform folliculitis with postinflammatory cha nges from older resolving lesions. A bacterial culture was taken from one of th e acneiform pustules at today s visit as he does have three to four of these prese nt on the back. Initially, we will start out with topical Benzefoam to be appli ed to the affected areas of the trunk, leave on two minutes and to shower and ri nse off. Samples and copay coupons were given for Benzefoam to the patient s moth er today in the office. I would also like for him after drying off in the showe r to apply a thin film of the Clindagel to the chest and back. We will follow u p in one week. At that time, the patient s mother states she will have the past m edication that he has used. At that time, we should also be able to see the res ults of the bacterial culture. We will tailor treatment plan at that time. I h ave advised the patient and his mother that we maybe doing a short course of dox ycycline and/or some other type of oral antibiotic therapy as his acne is primar ily inflammatory in nature and located on the trunk. Both patient and mother vo iced understanding. Follow up in one week. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Rosacea, both erythrotelangiectatic and papular in nature. The patient stat es this is often triggered by one coffee, beer and sometimes sun exposure. She states that MetroGel had worked well in the past and is open to doing another tr ial of the doxycycline. I have written her for MetroGel 1% 55 gram pump a large pump with one refill. I would like for her to use this daily, applying after w ashing face and spreading into a thin film. Also, I have written her for doxycy cline 20 mg caps, take one capsule p.o. b.i.d. I have written her for 60 with f our refills. Side effects of both medications were explained and reviewed with the patient. She voiced understanding. I have also asked the patient to try an

d hardest to avoid any triggers that she has noticed exacerbate the rosacea. Wi th regards to the Proactiv, she may continue on with this over-the-counter Align for cleansing and hydrating or she may have to do the Aveeno calming line of cl eansers and moisturizers if she would like to try. The importance of daily sun protection was discussed. The patient was given an informational brochure on sk in cancer and a starter sample of a complete sun block. For the erythrotelangie ctatic portion of the rosacea, I have advised the patient that laser would be th e best option for treatment. She has more telangiectasias present on the left c heek region. I have recommended a cosmetic consult with either Dr. Lawrence Cha ng or Dr. Cyndi Torosky to discuss her laser options for the vascular telangiect atic components of her rosacea. 2. Lentigo. The patient was reassured regarding the benign nature of these les ions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whe never they are exposed to the sun. Follow up will be in approximately four mont hs. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Mr. Taylor presents today for his yearly skin checkup. He does hav e a history of nonmelanoma skin cancer. He is a frequent traveler and states th at he resides in the tropics for most of the year. He is currently visiting his grandson. The patient continues to have no medications on file. He does have allergy to penicillin. The patient states no history of skin cancer. He does u se daily SPF of 30 or greater. 1. Actinic keratoses, one on the nasal tip, eight on the dorsum of the forearms , and four on the legs that were treated today for a total of 13 with liquid nit rogen cryotherapy x2 cycles. Postprocedure care and expectations were discussed with the patient. He understands. 2. Seborrheic keratosis: The patient was informed of the benign nature of thes e lesions and no treatment is necessary at this time. 3. Lentigo. The patient was reassured regarding the benign nature of these les ions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whe never they are exposed to the sun. 6. History of basal cell carcinoma. We discussed monthly skin checks, looking for any new or changing pigmented lesions. We also asked the patient to look fo r an irregular border, asymmetry, change in color or increase in diameter of any pigmented lesion. Today I reviewed sun protection guidelines. I discussed ABCD s and the use of suns creen. I also recommended monthly self skin exam. The patient understands we sho uld be notified for any changing lesions, new, or concerning lesions. I also dis cussed the use of wearing a hat and avoiding outdoor sun exposure at the peak su n hours. The importance of daily sun protection was discussed. The patient was given an informational brochure on skin cancer and a starter sample of a comple te sun block. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: On exam, the patient is a well-developed and well-nourished male, in no acute distress. I did examine the two areas of concern today. On the left pinkie, there is some xerosis present with loss of the lateral edge of the cutic le. It looks to be consistent with possible paronychia and the xerosis at the f ingertip with some flaking. Examination of the right foot in the interdigital w eb spaces, he does have some flaking along with some maceration, which looks to be suspicious for interdigital tinea pedis. He also has some xerosis at the pla ntar aspects of the feet bilaterally. 1. Dermatitis, not otherwise specified, of the left pinkie, likely consistent w ith paronychia. I have given the patient a tube of Lotrisone to be applied twic e daily to the area over the next two to four weeks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment.

SUBJECTIVE: Carolyn presents to the office today for a spot check on the left c heek, which she has had over the last week. The patient also has a history of b asal cell carcinoma on the right cheek and states minimal tanning bed use. 1. Lentigo, one irritated in nature on the left cheek, light courtesy freeze wa s done of this area with liquid nitrogen and cryotherapy x2 cycles. Postprocedu re care and expectations were discussed with the patient. She tolerated the pro cedure well. 2. Irritated seborrheic keratosis on the dorsum of the right wrist. This was t reated in the office today with liquid nitrogen and cryotherapy x2 cycles. Post procedure care and expectations were discussed with the patient. She tolerated the procedure well. 3. Seborrheic keratosis. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. The patient was asked what she might be able to do to get rid of some of the lentigines on more permanent basis. I have advised laser removal of these sun lesions secondary to sun damag e. I have advised her cosmetic consultation with Dr. Chang to discuss her laser options. The patient states she will schedule that as soon as her schedule all ows. At this time, her follow up with me is open-ended. When asked if she had done a total skin exam, the patient states that she already has one scheduled wi th another provider. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Jasmine presents today as an eight-month pregnant patient for acne and rash that she has had, which the patient states has been previously diagnose d as tinea versicolor. She states she has had the acne over the last few years and it has gotten worse with progression of the pregnancy. She gives no persona l or family history of skin problems otherwise. She states she has an aspirin a llergy. She is currently not taking any daily medications. She does have a his tory of diabetes, headaches, and stomach/bowel issues. She is a nondrinker and nonsmoker. 1. Acne vulgaris with postinflammatory changes. As the patient is eight months pregnant, we are limited in our options that are considered class B safety readi ng or above. Two class B that the patient may wish to try are clindamycin lotio n. I have written her for a 60 mg bottle, she may apply a thin film after washi ng the face each morning. I have advised CeraVe foaming face wash for a gentle non-medicated face wash to use in the morning followed by the clindamycin lotion . At night, she may have to wash her face with the CeraVe foaming face wash aga in and then follow with a small pea size amount of Finacea gel. I have given he r six samples and written her for the Finacea 15% gel a 50 gram tube take one pe a size amount and spread into thin film on face at night after washing. With re gards to the progression of her acne, I have advised the patient that it may bec ome worse as the pregnancy proceeds. While she is pregnant and subsequently whi le she is breastfeeding, our options will be limited. However, after she is don e with breastfeeding, we may then become more aggressive in our approach incorpo rating topicals such as Retin-A and also some oral antibiotics, possibly doxycyc line or minocycline into the regimen. The patient voiced understanding. 2. Tinea versicolor. I have talked with Dr. Robert Pariser regarding treatment for pregnant woman with regards to the tinea versicolor. He states that the be nzoyl peroxide over-the-counter washes are safe to use and often times will trea t the tinea versicolor quite effectively. I have asked the patient to consult w ith her OB prior to using the over-the-counter benzoyl peroxide acne wash as ben zoyl peroxide is indicated as class C in pregnancy. The patient states she will consult with her OB before beginning this program. Follow up will be once the patient has delivered. I have advised her to contact us and we will tailor trea tment plan at that time for her acne and reassess the tinea versicolor. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. MEDICATIONS: His medication list has been scanned into the patient corresponden ce file at today s visit. The patient states he does need to take amoxicillin pri or to having surgical and/or dental work done.

1. Irritated seborrheic keratoses on the vertex scalp. Two were treated in the office today with liquid nitrogen cryotherapy x2 cycles. Postprocedural ca re and expectations were discussed with the patient and he tolerated the procedu re well. 2. Skin tag, left cheek. This was removed in the office today by Dermatolo gy technician, Tabby Starkey via sterile snip procedure under aseptic technique. Tabby discussed wound care with the patient. He understands. Follow up at th is point will be on an open-ended basis. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Mr. McGlone presents today for repeat of his PPD reading. He showe d up today for a reading of a previous PPD, which was placed on June 6, 2012. D ermatology technician, Tabby Starkey has informed the patient that replacement w ill need to be done as the reading needs to take place 48 hours from date of pla cement. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Actinic keratoses. 13 were treated in all today on the dorsum of the fo rearms bilaterally as well as on the vertex scalp and the right cheek with liqui d nitrogen cryotherapy x2 cycles. Postprocedural care and expectations were dis cussed with the patient. He tolerated the procedure well. I have advised the p atient if the one on right cheek as well as the one on the left vertex scalp con tinue to persist then we will look at biopsying that at the next visit or sooner . The patient would also be a good candidate in the wintertime for another roun d of Efudex therapy to the vertex scalp. 2. Seborrheic keratosis. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. 3. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Mr. Cutchin presents today accompanied by his caregiver daughter fo r a six-month total skin exam. The patient does have a history of squamous cell carcinoma on the left inferior cheek, treated in December of 2011 by Dr. Lawren ce Chang. No smoking and no alcohol use. He is unsure of his family history of skin cancer. 1. Seborrheic keratoses. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. 3. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 4. Xerosis of the bilateral lower extremities. I discussed the importance of using a mild soap in the bath or shower such as Dove for sensitive skin, Oil of Olay, CeraVe or Cetaphil. We also talked about avoiding hot showers or baths and applying a thick emollient cream within three minutes of exiting the bath o r shower while the skin is still damp. Of note, some edema was seen too in the ankles and foot region. I have revisited his medication list. This is to be sc anned into the patient correspondence file. Additionally, I have recommended al so that aside from diuretics that the patient would benefit from a pair of compr ession stockings worn daily as often as possible along with elevation in his rec lining chair. His daughter voiced understanding and reiterated this to the pati ent Mr. Cutchin nodded approval as well. Follow up will be in one year for next total skin exam unless of course he needs us sooner. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: Physical examination reveals a well-developed and well-nourished Cau casian female, alert and oriented, in no acute distress. I did examine today th

e scalp, face, neck, trunk and bilateral upper and lower extremities to include buttocks region. Groin region was deferred at today s visit. On examination of t he upper and lower body, there are numerous light-tan and light-brown macules of various shapes and sizes consistent with solar lentigines as well as a few ligh t-brown to medium brown warty waxy stuck-on appearing papules consistent with se borrheic keratoses. There are also some symmetrical cherry red papules scattere d about the trunk consistent with cherry hemangiomas and a small scar located on the right chin from where cavernous hemangioma was surgically removed years bac k. The patient stayed stable and no changes. No actinic keratoses are present at today s visit. The patient states that the area of xerosis on the occipital re gion of the scalp evaluated last year has cleared up nicely with emollient moist urization. 1. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 2. Seborrheic keratoses. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. 4. History of basal cell carcinoma. The patient is meeting with Dr. Rosenb lum in one week to discuss if there is any need for third surgery. I would like to have her reevaluated in approximately six months to have the area of the nas al sidewall reexamined by a staff physician to ensure there is no recurrence of tumor given that it is still somewhat pink and swollen in nature and then I will be meeting with her in one year for her annual total skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Atopic dermatitis with generalized xerosis. I have given the patient a refill for triamcinolone, but I have increased the potency to the ointment as op posed to the cream. I have written her for a one-pound jar with one refill. Sh e may apply this twice daily as needed to flares. For the dyshidrotic component (for hands and feet), I have written her for a 60 gram tube of clobetasol ointm ent. This is to be applied twice daily as needed for flares only to the hands a nd feet. Side effects of the steroids were discussed with the patient in the of fice today. She voiced understanding and has been advised that if she feels she is using this on a continuous basis, she needs to follow up with the office at once. 2. Xerosis. I discussed the importance of using a mild soap in the bath or shower such as Dove for sensitive skin, Oil of Olay, CeraVe or Cetaphil. We al so talked about avoiding hot showers or baths and applying a thick emollient cre am within three minutes of exiting the bath or shower while the skin is still da mp. I have advised the patient that fragrance may indeed be the culprit for som e of this dermatitis as she is using highly fragranced nut butter lotions and sc ented Dove soap. I have advised Dove for sensitive skin soap and given her thre e samples in office today. I have also given her some 2$ off coupons for the Ce taphil Restoraderm lotion and wash. She may wish to do the 50:50 mix of the Cet aphil Restoraderm lotion with the Vaseline Petroleum jelly, which she may obtain at the dollar stores. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: Physical examination reveals a well-developed well-nourished young C aucasian female, in no apparent distress. On examination of the bilateral lower extremities, she does have a couple of four to six inflammatory papules present in various stages of resolution. The most visible are the ones on the flexor s urface of the right foot. No interdigital involvement is noted and this does no t look to be scabies in nature. I do believe this is more consistent with insec t bite type reaction. It does not look to be a staph abscess either. No pustul es are noted. No signs of infection either. The patient also does have some sy mmetrical benign-appearing nevi 2-3 mm in diameter, dark-brown, well-circumscrib ed and evenly pigmented throughout. 1. Dermatitis, not otherwise specified, likely insect bite reaction. I hav

e given the patient some samples of the topical ointment to use twice daily to t he area as needed for itch. If she is not better at two weeks time, we will see her back and discuss the short course of doxycycline therapy. 2. Benign nevi on the legs. These are all well marginated, homogenously pi gmented, symmetrical, benign appearing moles. We reviewed the ABCD s of melanoma, and a handout detailing this information was given to the patient. The patient understands that if any of these lesions begin to change, they are to return to clinic for re-evaluation. Today I reviewed sun protection guidelines. I discu ssed ABCD s and the use of sunscreen. I also recommended monthly self skin exam. T he patient understands we should be notified for any changing lesions, new, or c oncerning lesions. I also discussed the use of wearing a hat and avoiding outdoo r sun exposure at the peak sun hours. Follow up at this point is open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: Physical examination reveals a well-developed and well-nourished Afr ican-American female, in no apparent distress. On examination of the area of co ncern today which is the face, she does have numerous areas of patchy hypopigmen tation present, most notably on the left forehead and left bitemporal region, lo oks to be consistent with pityriasis alba. There is some well-demarcated hypopi gmented patches as well on the right base of the neck. She does have some gener alized fine flaking in the region consistent with her dry skin. The patient als o points to antecubital fossa bilaterally and states that she has had some irrit ation in this area as well. Physical examination reveals some lichenified hypop igmented areas, which looks to be consistent with atopic distribution. 1. Pityriasis alba. I have explained to the patient the etiology and treat ment for pityriasis alba. I am going to start with Elidel cream. She may apply this twice daily to the affected areas of the face as well as the hypopigmented area on the right base of the neck. I have prescribed the patient a 60 gram tu be of the Elidel, which I would like for her to use twice daily to the affected region over the next four weeks and then reevaluate. I have advised the patient this may go on somewhat tingly in nature for the first few applications. The p atient voiced understanding. 2. Dermatitis, not otherwise specified of the bilateral antecubital fossa. This is atopic distribution and is likely mild flare-up of eczema. The patient states it is mild in nature, but it does itch. I have advised the patient she may opt to use some of the Elidel that she uses to treat the face to the antecub ital fossa as well. I have given her enough medication to treat both areas over the next month. Follow up will be in four to six weeks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: LaQuan presents to the office today for some spotting he has discov ered on the back of his neck. He says it is not symptomatic and does not bother him. He has noticed that it appeared approximately four to five months ago. T he patient gives no personal or family history of skin problems in the past. He is not allergic to any medications nor is he on any daily medications. He does drink alcohol. He does not smoke tobacco. ASSESSMENT/PLAN: Tinea versicolor with postinflammatory hyperpigmentation and x erosis. I have given the patient today a prescription for ketoconazole shampoo. I would like for him to use this as a body wash entering into the shower and a pplying and leaving on 5 minutes and then rinsing for a daily period of two week s. After two weeks, I would like for the patient to use this twice weekly to ke ep yeast and fungus overgrowth at bay. Follow up will be on an open-ended basis . The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Neoplasm, uncertain central mid back, just left of center, rule out atyp ical nevus versus dysplastic nevus versus malignant melanoma. Border changes, p igment changes, and size greater than 6 mm does leave me suspicious for the diag nosis of malignant melanoma. Under aseptic technique and 1% lidocaine the lesio n was removed with a DermaBlade technique. Electrodesiccation was applied to th

e base. A dry dressing with Polysporin was applied and wound care instructions w ere given. The proposed procedures, alternatives, risks and benefits were discus sed with the patient. Follow up will be based on the pathological diagnosis and as needed. The patient was informed that they will be made aware of the result s in two to three weeks either by phone or via mail. If they do not hear from u s in four weeks they are to call us. This was done in office today by dermatolo gy technician, Taby Starkey. I have informed the patient pathology results will be back in approximately two weeks. At that time, we will be in touch with the patient for followup. 2. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 3. Actinic keratosis, three on the vertex scalp were treated in office toda y with liquid nitrogen cryotherapy x2 cycles. Postprocedural care and expectati ons were discussed with the patient. He tolerated the procedure well. Follow u p will be based on pending pathology results. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: On exam, she is a well-developed, well-nourished, Caucasian female, in no apparent distress. I did examine the scalp, face, neck, trunk, and bilate ral upper and lower extremities including the buttocks region. On examination o f the sun exposed areas of the trunk, she does have too numerous to count scatte red solar lentigines of various shapes and sizes, light-tan, light brown in natu re. She also does have numerous warty waxy stuck-on appearing plaques mainly on the back consistent with seborrheic keratoses approximately four of which are d irectly in the bra line and are highly irritating causing significant discomfort to the patient. On the right thigh, she does have hyperpigmented lichenified p apule consistent with dermatofibroma. On the central back, she does have an ind urated nodule with central puncta suspicious for epidermal inclusion cyst on the central back. One is present on the upper shoulder as well with a central punc ta and is smaller and likely able to expressed with comedone in office today. 1. Neoplasm most likely epidermal inclusion cyst of the mid back. Under as eptic technique and 1% lidocaine the lesion was removed with a punch excision. Nylon sutures were placed. Polysporin and a pressure bandage were placed and wo und care instructions were given. The proposed procedures, alternatives, risks and benefits were discussed with the patient. Follow up will be based on the pa thological diagnosis and as needed. The patient was informed that they will be made aware of the results in two to three weeks either by phone or via mail. If they do not hear from us in four weeks they are to call us. This was done in o ffice today by both myself with dermatology technician, Taby Starkey assisting. I have advised the patient that followup will be pending pathology results. 2. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 3. Dermatofibroma, right thigh. The patient was reassured of the benign na ture of this condition-no treatment is necessary. 4. Comedone on the left upper shoulder. This was extracted as a courtesy t o the patient with the comedone extractor under aseptic technique. 5. Seborrheic keratosis. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. 6. Irritated seborrheic keratoses. One was treated on the right central ch est area near the bra line, four were treated on the back around the bra line th e ones that which were highly irritating to the patient with liquid nitrogen cry otherapy x3 cycles. Postprocedural care and expectations were discussed with th e patient and she tolerated the procedure well. Follow up will be pending path ology results; otherwise, followup will be at the patient s request. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment.

SUBJECTIVE: Sandra presents to the office today for a mole on the face as well as rash on the middle of the back. She has a mole of concern on her left forehe ad. She states she has had a couple of moles there all her life including this one, but she has noticed lately that the mole of concern has been growing and is causing somewhat of a dull pain. The patient states that it is not a lancing o r shooting type of pain. It just is a dull pain, which she notices intermittent ly. 1. Dermatitis, not otherwise specified with xerosis. In the differential t oday is keratosis pilaris, nummular dermatitis, and possibly allergic contact de rmatitis. I have done a fungal culture today in office by dermatology technicia n, Tammy Chisholm to rule out fungal entity. In the interim, I am giving the pa tient triamcinolone 0.1% cream 60 g tube. I would like for her to use this twic e daily for the next two weeks to the affected areas of the back. If the DTM cu lture does come back as positive for fungus, we will re-tailor treatment plan at that time. Otherwise, if it does come back as negative and the itchiness and d ryness has cleared with two-week use of the triamcinolone, we will have the pati ent continue on with the triamcinolone only as needed for flare-ups. 2. Neoplasm uncertain of the left forehead, likely intradermal nevus, which the patient would like removal of. I have discussed with the patient that this will be a consult and decision left up to our dermatologic surgeon, Dr. Chang. He may either opt to remove the mole of concern himself or he may be referring out to a plastic surgeon based on the location and the surgeon s preference. The patient voiced understanding. 3. Benign nevi on the back. These are all well marginated, homogenously pi gmented, symmetrical, benign appearing moles. We reviewed the ABCD s of melanoma, and a handout detailing this information was given to the patient. The patient understands that if any of these lesions begin to change, they are to return to clinic for re-evaluation. I have also advised a gentle skin care regimen as th e patient has some dry patches on the back. She is currently using regular Dove , Gain detergent and Cetaphil lotion. I have advised her that Cetaphil lotion i s perfectly appropriate; however, I have recommended switching out to Dove For S ensitive Skin face and body wash samples of which were given in office today and switching from the Gain detergent to the _____ detergent to see if this helps a t all. If the patient has not experienced improvement in the next two weeks, I would like for her to follow back up to the office. Otherwise, her next followu p will be with Dr. Chang for a consult with regards to the intradermal nevus on the forehead. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: On examination, she is a well-developed, well-nourished, Caucasian f emale, in no apparent distress. I did examine today the scalp, face, neck, trun k, and bilateral upper and lower extremities. On the sun exposed areas of the b ody, she has numerous slight tanned light brown macules various shapes and sizes consistent with solar lentigines. She also does have some symmetrical cherry r ed papules mainly above the trunk consistent with hemangioma. She does have som e generalized xerosis of the lower extremities bilaterally, especially on the pl antar aspects of the feet bilaterally and a flesh-colored 1 mm firm papule on th e left nasal ala consistent with fibrous papule. The scar on the left medial ca nthi is well-healed and well-approximated. No sign of general recurrence is pre sent at today s visit. The patient is very subconscious with regards to the scatt ered solar lentigo on the chest. She is interested in finding more about cosmet ic laser removal. 3. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. Additionally, the patient has inquired in to laser removal. I have given her the information for Dr. Lawrence Chang and I have recommended a cosmetic consult for laser removal of her solar lentigines on the chest wall area. 4. History of BCC, left medical canthi. We discussed monthly skin checks,

looking for any new or changing pigmented lesions. We also asked the patient to look for an irregular border, asymmetry, change in color or increase in diamete r of any pigmented lesion. Today I reviewed sun protection guidelines. I discu ssed ABCD s and the use of sunscreen. I also recommended monthly self skin exam. The patient understands we should be notified for any changing lesions, new, or concerning lesions. I also discussed the use of wearing a hat and avoiding outd oor sun exposure at the peak sun hours. 5. Fibrous papule on the left nasal ala, asymptomatic and stable. Continue annual surveillance. The patient will be seen for annual surveillance with onc e yearly total skin exam. However, her next followup will likely be with Dr. Ch ang to discuss cosmetic removal of some scattered solar lentigines on the chest wall. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Neveah presents to the office today for a followup of seborrheic de rmatitis. She was given Derma-Smoothe FS Oil for the scalp at her last date of service 05/16/2012 and a DTM was inoculated on 05/16/2012, which was read by Dr. Robert Pariser on 05/31/2012. Per RJP, the culture was indeterminate. The pat ient s mother has accompanied her today and states that she has responded nicely t o the Derma-Smoothe Oil. She has used it a couple of times and states that the patient is having no more hair breaking and is not having problems with itching. The patient s mother does report a personal history for Neveah of seasonal aller gies and states a family history of eczema on Neveah s father s side as well as niec e with asthma. ASSESSMENT/PLAN: Dermatitis, not otherwise specified, likely seborrheic dermati tis with xerosis. We will continue her on the Derma-Smoothe Oil as needed for f lares at night. The patient s mother state she is good on refills today. Follow up will be on an open-ended basis. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. History of BCC. We discussed monthly skin checks, looking for any new o r changing pigmented lesions. We also asked the patient to look for an irregula r border, asymmetry, change in color or increase in diameter of any pigmented le sion. Today I reviewed sun protection guidelines. I discussed ABCD s and the use of sunscreen. I also recommended monthly self skin exam. The patient understan ds we should be notified for any changing lesions, new, or concerning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at t he peak sun hours. 2. Actinic keratosis, left nasal side wall. This was treated with liquid n itrogen cryotherapy x2 cycles. Postprocedural care and expectations were discus sed with the patient. He tolerated the procedure well. 3. Dermatitis, not otherwise specified. Possibly just a xerotic patch on the r ight arm versus nummular dermatitis as it has presented some itching to the pati ent in the past. I have given him sample of Topicort ointment to apply twice da ily over the next week or two. If it does not appear, I would like the patient to follow back up to the office. 4. Dermatofibroma, left medial ankle. The patient was reassured of the ben ign nature of this condition-no treatment is necessary. 5. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 6. Seborrheic keratosis. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. We would follow up in one year for his next total skin exam, unless of course he needs us sooner. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Auriel presents to the office today for followup of two-week trial of ketoconazole for yeast folliculitis in the forehead and bitemporal region. T he patient is accompanied today by her mother and both of them state noticeable

added improvement with use of the ketoconazole use twice daily over the past two weeks. The patient s mother has not gotten the prescription yet for the Triple c ream. She plans to do that this week and then we will meet back in three months to reassess use of the Triple cream as well. OBJECTIVE: Physical examination reveals a well-developed, well-nourished, young African-American female, accompanied by her mother and sister in office today, in no acute distress, alert and oriented. She does have a noticeable reduction of the sandpapery like flesh-colored dime shaped papules on the forehead bitempo ral region; however, some are still persisting. They are couple on the base of the neck line as well. The patient also continues to have open and closed comed ones present in T zone region on the forehead, nose, and chin and some milia pre sent on the cheeks, bitemporal region, and forehead as well. 1. Acne vulgaris with some postinflammatory changes from older resolving le sions and some milia. The patient s mother states she is filling the prescription for Lakeview Pharmacy Triple cream today. I have advised the patient once she has used over two to three months, we will reassess at that time to see whether or not things have improved. 2. Yeast folliculitis forehead and bitemporal region improved on ketoconazo le cream used twice daily. I have advised the patient as she may go down to twi ce weekly use to help keep yeast and fungal overgrowth at bay. She is good on r efills at this time. Follow up will be in three months for acne followup. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\patricia jill samples consolidated\06-12-12\061212_pjl.doc 7/28/2012 1:02: 26 PM 143872 1. Neoplasm of uncertain left chest at the inferior border of the scar from whi ch the basal cell carcinomas removed in November of 2011, rule out BCC recurrenc e versus ruptured hair follicle. Under aseptic technique and 1% lidocaine the l esion was removed with a DermaBlade technique. Electrodessication was applied t o the base. A dry dressing with Polysporin was applied and wound care instructio ns were given. The proposed procedures, alternatives, risks and benefits were di scussed with the patient. Follow up will be based on the pathological diagnosis and as needed. The patient was informed that they will be made aware of the re sults in two to three weeks either by phone or via mail. If they do not hear fr om us in four weeks they are to call us. 2. Verruca on the left index finger. The lesion was treated with liquid nitroge n cryotherapy x3 cycles. Postprocedural care and expectations were discussed wi th the patient and he tolerated the procedure well. 3. Lentigo. The patient was reassured regarding the benign nature of these les ions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whe never they are exposed to the sun. 5. History of BCC. We discussed monthly skin checks, looking for any new or ch anging pigmented lesions. We also asked the patient to look for an irregular bo rder, asymmetry, change in color or increase in diameter of any pigmented lesion . Today, I reviewed sun protection guidelines. I discussed ABCD s and the use of sunscreen. I also recommended monthly self skin exam. The patient understands we should be notified for any changing lesions, new, or concerning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours. Follow up will be pending pathology results. Otherwise, if al l comes back as benign, we will see Mr. May back in approximately one year for h is next total skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Zachary presents today for his initial Botox axillary hyperhidrosis treatment. The patient denies any history _____ otherwise of multiple scleros is. Current drug allergies include Vicodin. ASSESSMENT/PLAN: Botox injections for axillary hyperhidrosis. A 100 units vial

was used lot #C3040 C3, expiration date December of 2014. The axillary vaults were cleaned with sterile alcohol swabs. Under aseptic technique, approximately 50 units were injected into the left axillary vault and 50 units injected into the right axillary vault. The patient tolerated the procedure well with minimal bleeding and bruising. I have advised the patient no physical therapy today or any strenuous exercises for the next 24 hours. Botox is diluted 100U/4.0 ml di lution of saline. The affected area was divided into a grid pattern with each i njection site being approximately 1-2 cm apart. Explanation regarding the dispe rsion of Botox being 1-2 cm when placed intra-dermally was provided. Under anti -septic precautions, using a 30-gauge needle, Botox is injected intradermally in to the bilateral axilla ensuring that a bleb was is raised. Injections were spre ad out evenly, starting from the periphery and moving to the center, ensuring ev en coverage of the injections. Explanation provided regarding perceived benefit within 1-2 weeks and duration of relief from 6-14 months. Follow up will be pe nding breakthrough sweating. I have given him the number for Amanda McWilliams, which he may contact once that does occur. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: He is a well-developed, well-nourished, African American male, who app ears younger than stated age, alert and oriented cumbersome with a nontoxic appe arance. He is Fitzpatrick type V. He does have some lichenification and hyperp igmentation of the skin along with some fine flaking consistent with xerosis and age-related changes of the skin on the dorsal aspect of the forearms bilaterall y. On the volar aspect of the right forearm, he does have one vesicle. It does not appear to be on the erythematous base. The patient states that the arms ha ve been somewhat dry and itchy where he is having another shingles outbreak when he saw the blister. 1. Dermatitis, not otherwise specified, rule out herpes versus blistering proce ss. The patient was seen by both myself and Dr. Molly Smith in office today. S he is recommended a punch biopsy of the area for further diagnostic value. Afte r obtaining written consent, the patient was prepped with alcohol. Buffered Lido caine with epinephrine 1% was administered for local anesthesia. The specimen w as obtained with a 6-mm punch biopsy. 4-0 nylon suture was placed. Drysol was used for hemostasis. Polysporin ointment was applied and the wound was bandaged . Wound care instructions were reviewed. The patient tolerated the procedure w ell. Pathology results will be mailed to the patient. This was done in the off ice today by dermatologic technician Kelly Walker. 2. Xerosis with element of lichen simplex chronicus on the dorsum of the forear ms bilaterally. The patient will continue on with using his triamcinolone cream twice daily for symptomatic relief until biopsy results can be obtained. The p atient will return in approximately 12 to 14 days for suture removal. At that t ime, we can discuss pathology results and maintain other treatment plan as neces sary. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Phyllis presents to the office today for annual skin exam. The pat ient gives no personal or family history of skin cancer. She does admit to blis tering sunburns as a child. She denies tanning bed use. OBJECTIVE: Physical examination reveals a well-developed, well-nourished Caucas ian female, in no apparent distress. I did examine the scalp, face, neck, trunk , and bilateral upper and lower extremities including the buttocks region on tod ay s visit. Groin region was deferred today. On examination of the sun exposed a reas of the upper and lower body, she has numerous light-tan, light-brown macule s of various shapes and sizes consistent with solar lentigo as well as some ligh t-tan, medium brown warty waxy stuck-on appearing papules mostly notably about t he back consistent with seborrheic keratoses and some symmetrical cherry red pap ules most notably concentrated on the chest and abdomen consistent with cherry h emangioma. She does also have some spider telangiectasias present on both poste rior and anterior aspect of the thighs bilaterally. On the chin, she does have some hyperpigmentation consistent with melasma. She also does have horny hyperk

eratotic crumbling appearance to all 10 toenails, which looked to be consistent with onychomycosis. There is some fine flaking of the plantar aspects of the fe et bilaterally consistent with xerosis. The patient states she is seeing a podi atrist for these concerns. 1. Lentigo. The patient was reassured regarding the benign nature of these les ions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whe never they are exposed to the sun. 2. Spider telangiectasia. I explained to the patient the benign nature of this condition and discussed options for cosmetic treatment. No treatment was perfo rmed during today's visit. 3. Seborrheic keratosis. The patient was informed of the benign nature of thes e lesions and no treatment is necessary at this time. 5. Melasma. I have given the patient a cosmetic information sheet for Dr. Cind y and Dr. Chang with regards to their prices for laser treatment. The patient i s interested in laser treatment for melasma and will follow up with them accordi ngly. 6. Nail disease likely onychomycosis with 10 nail involvement with xerosis of t he foot likely callus secondary to her stance. The patient states she is seeing a podiatrist for these concerns. The importance of daily sun protection was di scussed. The patient was given an informational brochure on skin cancer and a s tarter sample of a complete sun block. Today, I reviewed sun protection guideli nes. I discussed ABCD s and the use of sunscreen. I also recommended monthly sel f-skin exam. The patient understands we should be notified for any changing les ions, new, or concerning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours. Follow up with me in one year for her next total skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Vickie comes to us today referred by Dr. Jitendra Patel. I thank h im for the referral that I have appreciated. She states that she is in today fo r some itchiness on the back as well as a couple of itchy areas on the anterior aspect of both shins and dorsum of the right foot. She states she has had this on the legs for approximately the last six years. She states that she has had s ome dry patchy areas on the face for the last month. The patient denies any per sonal history of skin problems, but states that her mother did have some skin co ndition in the past for which she is unsure. The patient states no known drug a llergies. She is currently taking HCTZ, Prozac, Restoril, and Flonase. She als o gives a history of seasonal allergies. She is not trying to get pregnant. Sh e is a nondrinker and nonsmoker. ASSESSMENT/PLAN: Seborrheic dermatitis with xerosis. For the face, I have give n the patient a 60 g tube of ketoconazole. I would like for her to apply those once in the morning. At night, she is to apply desonide cream to the same area. I have given her 30 g tube of the desonide cream with one refill. For the der matitis on the legs and for the spongiotic appearing patch on the dorsum of the right foot, I am going to give her triamcinolone 0.1% ointment. I would like fo r her to apply this twice daily over the next two weeks. With regards to the vi tiligo on the shins, I would like to get the nummular dermatitis present in this region calm down first prior to addressing concerns of discoloration. The pati ent agrees that she would like to prioritize the itching and irritation as well prior to worrying about the re-pigmentation concerns. In the future, we might o pt to do a trial of Protopic ointment to the area twice daily over a period of 4 8 weeks to see if any re-pigmentation will occur, although I have informed the p atient that it is a possibility in this region re-pigmentation may not occur des pite topical treatment. The patient understands and follow up in two weeks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Acne vulgaris of the right lower lip. Two comedones were extracted today us ing a comedone extractor under aseptic technique. The patient was also given so me samples of Retin-A to try to help resolve these two areas. I have advised he

r to start using this twice weekly on perhaps Monday and Friday titrating up to every other night or nightly use only if tolerated. Side effects of the medicat ions were reviewed with the patient and she understands 2. DPN. I have informed the patient has a benign nature of the skin condition. No treatment is necessary at this time. 3. Seborrheic keratosis. The patient was informed of the benign nature of thes e lesions and no treatment is necessary at this time. 4. Skin tags on the neck. As these are not cancerous, the patient does not wis h to proceed with any cosmetic removal or treatment. Therefore, no treatment ha s been done at this time. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Lara presents to the office today for some acne on the face and few inflammatory lesions on the back as well as a couple of moles that she states s he would like to have removed today in office today. There is one on the left t high, which she states has changed in texture and has noticed a fussy border aro und. She also has one on the left axillary vault, which has just recently appea red. It continues to catch on her razor and is highly irritating to the patient . 1. Acne vulgaris with postinflammatory changes. As the patient has tried many treatments with regards to acne in the past, I have set down and re-visited with her anything she thought may have worked particularly well. She does state tha t the minocycline did very good for the inflammatory component of her acne. The refore, I am going to start her back on triple therapy, as I did not feel she ha s a case bad enough to warrant Accutane therapy at this time. She will start by using Acanya Gel. I have written her for a 50 g pump. She is to apply one pum p to the face q.a.m. She is then to take a Solodyn 90 mg tablet one by mouth q. d. I have written her for a 90-day supply. and then at night, she will increase the strength of her Tazorac to Tazorac 0.1% cream. I have advised the patient on all the side effects of the medications. They were reviewed with the patient in the office today. She voiced understanding. The patient has also been told to start the retinoid twice weekly titrating up to every other night or nightly use only if tolerated. 2. Neoplasm uncertain of the left thigh rule out AN versus DN versus compound n evus. Lentigines junctional nevus. After obtaining a written consent, the pati ent was prepped with alcohol. Buffered Lidocaine with epinephrine 1% was admini stered for local anesthesia. The lesion was biopsied via a shave technique usin g a Dermablade. Drysol was used for hemostasis. Polysporin ointment was applie d to the wound and covered with a bandage. Wound care was reviewed. The patien t tolerated the procedure well. Pathology results will be mailed to the patient . 3. Neoplasm uncertain of the left axillary vault. Rule out AN versus DN versus compound nevus. After obtaining a written consent, the patient was prepped wit h alcohol. Buffered Lidocaine with epinephrine 1% was administered for local an esthesia. The lesion was biopsied via a shave technique using a Dermablade. Dr ysol was used for hemostasis. Polysporin ointment was applied to the wound and covered with a bandage. Wound care was reviewed. The patient tolerated the pro cedure well. Pathology results will be mailed to the patient. I have advised t he patient to follow up for the lesions of concern today and will be pending pat hology results. Otherwise, we will see her in two to three months for her acne followup. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Mr. Al Yami presents today for acne in the paranasal and bilateral malar cheeks region. He states that they are usually red and hard to surface. He states that he also does have some comedonal involvement primarily in the for ehead, nose, and chin region. The patient is a new patient to the practice. He denies any history personal or family of skin problems. He has not been treate d by any other doctors for any other problems. He is not allergic to any medica tions that he knows of. He is not taking any daily pills. He is a nondrinker a

nd nonsmoker. He states he did use oral medication in the past, but states he i s unsure what the name was. ASSESSMENT/PLAN: Acne vulgaris with milial cyst involvement and some postinflam matory changes remotely resolving lesions. I have started the patient acne regi men to include Neutrogena acne wash, which he may obtain over-the-counter. I ha ve given him some samples in the office today to start with. I would like for h im to take a Doryx 150 mg tablet one p.o. q.d. I have written him for a 90-day supply. Additionally at night, he will do a pea-sized amount of Epiduo gel to t he face apply as a pea-sized amount spread into a thin film. I have written him for a 45 g pump and I would like to see him back for followup in approximately two months. Side effects of the medications were discussed and reviewed with th e patient and in the office today. He voiced understanding. Follow up in two mo nths. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: On examination, she is a well-developed, well-nourished Caucasian fe male, in no acute distress. She does have a well-healing, well-approximated wou nd with stitch present on the left lower lip. No signs of streaking or infectio n are noted. No purulent drainage. The patient denies any fevers, sweats, or c hills _____ biopsy. She does have significant edema present on the left lower l ip quadrant. ASSESSMENT/PLAN: Neoplasm uncertain of the lower lip, wound check. Dr. Molly w as brought in to see the patient. She agrees that no infection is present. We have advised the patient to add a pillow so that she may sleep on incline during tonight sleep and I have also recommended using an antihistamine such as Zyrtec , Claritin, or Allegra during the daytime for non-drowsy relief of swelling. At night, I have given her Atarax. She may take 1-2 of these at night and follow up to the office in approximately one week for her suture removal. Dr. Molly ha s informed the patient that the swelling can take anywhere from three to four da ys to resolve. I have reassured her that no hematoma is present nor any signs o f pending infection. The patient was reassured and sent home with all concerns and questions answered. We will see her in approximately one week for suture re moval. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: On examination today, he is a well-developed, well-nourished elderly Caucasian male, in no acute distress. I did examine today the scalp, face, nec k, trunk, and bilateral upper and lower extremities including the buttocks and i ncluding the anogenital region. Inguinal node check was done revealing no abnor mal lymphadenopathy. There has been some swelling noted in the left lower quadr ant of the abdomen. The patient has been referred to his primary care physician by this office in the past. The primary care physician has stated that he feel s this does not warrant further investigation. On examination of the sun expose d areas of the body, he has numerous light-tan, light-brown macules of various s hapes and sizes consistent with solar lentigines and some light-tan, light-brown , warty waxy stuck-on appearing papules and plaques mainly on the back and chest consistent with seborrheic keratoses. There are some symmetrical cherry red pa pules scattered about the abdomen consistent with cherry hemangioma and on the f ace, he does have numerous flesh-colored dome-shaped papules with central umbili cation consistent with sebaceous hyperplasia. On the right infraorbital rim, he does have two pink pearly papules, one with a rolled border, enlarged central d epression, one with a couple of telangiectasias one directly superior to that wi th some telangiectasias present. For these both rule out basal cell carcinoma v ersus sebaceous hyperplasia. He does have on examination of the vertex scalp fi ve ill-defined waxy, erythematous plaques consistent with actinic keratoses. 1. Neoplasm uncertain of the right infraorbital rim, one superior and one i nferior. Both impressions are rule out sebaceous hyperplasia versus BCC. Shave removals were done for both of these. Under aseptic technique and 1% lidocaine , the lesion was removed with a DermaBlade technique. Electrodessication was ap plied to the base. A dry dressing with Polysporin was applied and wound care ins

tructions were given. The proposed procedures, alternatives, risks and benefits were discussed with the patient. Follow up will be based on the pathological di agnosis and as needed. The patient was informed that they will be made aware of the results in two to three weeks either by phone or via mail. If they do not hear from us in four weeks they are to call us. 3. Seborrheic keratosis. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. 4. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 5. Sebaceous hyperplasia. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. 6. Actinic keratoses. Five were treated today on the vertex scalp with liq uid nitrogen cryotherapy x2 cycles. Postprocedure care and expectations were di scussed with the patient. He tolerated the procedure well. Follow up with me i n approximately six months pending pathology results. His next total skin exam is scheduled for six months; however, I have informed the patient if either one of the biopsies do come back as cancerous in nature, we will be getting in touch with him sooner after pathology results will be available in approximately two weeks. The patient voiced understanding. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Lentigo with structural changes. I have advised the patient to try some samples of Tazorac 0.1% cream to see if that helps at all with improvement of s kin texture. If she wishes, I am happy to write her for 60 g tube of Tazorac af ter trying out these samples. 3. Sun damage. Poikiloderma. The importance of daily sun protection was d iscussed. The patient was given an informational brochure on skin cancer and a starter sample of a complete sun block. We also asked the patient to look for a n irregular border, asymmetry, change in color or increase in diameter of any pi gmented lesion. Today, I reviewed sun protection guidelines. I discussed ABCD s and the use of su nscreen. I also recommended monthly self-skin exam. The patient understands we should be notified for any changing lesions, new, or concerning lesions. I als o discussed the use of wearing a hat and avoiding outdoor sun exposure at the pe ak sun hours. Follow up will be open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Conner presents to the office today for a large plantar wart on the left heel, which has been bothering him over the last six months. He states it is painful to run. The patient gives no other personal or family history of sk in problems in the past. They have not been home wart treatment as of yet. He is not allergic to any medications that he knows of. He has been treated by oth er physicians for allergies, asthma, and ADHD. He is currently on Singulair, al buterol as needed and Concerta. He has past history of allergies and eczema as well as a history per his mother of abdominal migraines. ASSESSMENT/PLAN: Verruca plantar. The lesion was treated today in office with liquid nitrogen, cryotherapy x3 cycles. Postprocedural care and expectations we re discussed with the patient. He tolerated the procedure well. Both the patie nt and mother were explained the process of the home wart treatment. I have adv ised him if he wishes to come back in four to six weeks for another touchup, I a m happy to do so. Meanwhile, they will do the home wart treatment nightly to ev ery other night as their schedule allows. I have advised the patient and his mo ther that wart can take anywhere from three to five months for resolution and po ssibly longer. Both the patient and mother voiced understanding. I have advise d them to contact office if they have any questions, otherwise followup in four to six weeks. He is referred by Dr. Jane Robertson. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment.

1. Neoplasm uncertain right cheek. Rule out HDAK versus BCC versus SCC. A fter obtaining a written consent, the patient was prepped with alcohol. Buffere d Lidocaine with epinephrine 1% was administered for local anesthesia. The lesi on was biopsied via a shave technique using a DermaBlade. Drysol was used for h emostasis. Polysporin ointment was applied to the wound and covered with a band age. Wound care was reviewed. The patient tolerated the procedure well. Patho logy results will be mailed to the patient. 2. Benign nevi on the face. All nevi are well marginated, homogenously pig mented, symmetrical, benign appearing moles. We reviewed ABCDs of melanoma. Th e patient will monitor moles for any change or growth. The patient understands if any of these lesions begin to change, they are to return to clinic for re-eva luation. 3. History of BCC, left flank. We discussed monthly skin checks, looking f or any new or changing pigmented lesions. We also asked the patient to look for an irregular border, asymmetry, change in color or increase in diameter of any pigmented lesion. Today, I reviewed sun protection guidelines. I discussed ABCD s and the use of sun screen. I also recommended monthly self skin exam. The patient understands we should be notified for any changing lesions, new, or concerning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at the pea k sun hours. Follow up will be pending pathology results. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Actinic keratoses of the face. Three total were treated today with liqu id nitrogen cryotherapy x2 cycles. Postprocedural care and expectations were di scussed with the patient. He tolerated the procedure well. 2. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 3. Melasma. The patient has inquired into peels with regards to the melasm a. I have quoted him on the phrases for the Glytone glycolic acid peels as well as for the SkinMedica Rejuvenate peel. The patient states he will be looking i nto this in the fall or wintertime. I have advised the patient to start approxi mately three to four peels are necessary to see a subtle result. He may also be interested in laser options in the future. 4. History of non-melanoma skin cancer. We discussed monthly skin checks, looking for any new or changing pigmented lesions. We also asked the patient to look for an irregular border, asymmetry, change in color or increase in diamete r of any pigmented lesion. Today, I reviewed sun protection guidelines. I disc ussed ABCD s and the use of sunscreen. I also recommended monthly self-skin exam. The patient understands we should be notified for any changing lesions, new, o r concerning lesions. I also discussed the use of wearing a hat and avoiding ou tdoor sun exposure at the peak sun hours. Follow up will be this December to de termine whether or not the patient wishes to do any type of glycolic acid peels. Follow up in six months for a repeat total body skin check and discussion of c hemical peels. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Mr. Register presents today for a few areas of concern. He states that he has had some areas on the back that have been burning and irritating to him in nature. He states that while it does not look like he has any primary le sion present, he begins to dig and dig as the pain is somewhat lancinating and s tates that he is very frustrated by this. The patient denies any personal or fa mily history of skin cancers. He does admit to blistering sunburns extensive in nature as a child. He has no other family or personal history of skin problems . He is not allergic to any medications and is currently on lisinopril 20 mg an d Prilosec. With regards to any type of neck or back injuries, he does state th at he hurt his back during baseball season as a team and states he has injured h is neck a couple of times doing squats as a young adult.

1. Dermatitis, not otherwise specified with some fine flaking consistent wi th xerosis. I favored the diagnosis of seborrheic dermatitis given the history of itchy scalp. I have given the patient ketoconazole shampoo, which I would li ke for him to use daily for a period of two weeks, apply as a scalp soaking sham poo and body wash, leave on five minutes and then rinse for two weeks. I would also like for him to apply some triamcinolone twice daily to the affected area o f the back as it looks somewhat inflamed in nature. We will reevaluate in two w eeks to see if this has given him any relief. 2. Irritated seborrheic keratosis. Left bitemporal region. _____ liquid n itrogen cryotherapy x3 cycles. Postprocedural care and expectations were discus sed with the patient. He tolerated the procedure well. 3. Seborrheic keratoses. The patient was informed of the benign nature 4. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 5. Hemangioma. The benign nature of the lesions was discussed and no treat ment is necessary at this time. Follow up in two weeks to reassess. Additional ly, I have advised to the patient use a non-scented Dove soap for sensitive skin body wash. I have also advised him to remove any fragrance products from his r egimen over the next two weeks to include his Axe exfoliant, his Dial soap and a ny other fragrance lotions. I have also advised him to put his after shave on o nly to his clothes and avoid any contact with the skin. Reevaluation in two wee ks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ASSESSMENT/PLAN: I have discussed with the patient that this is third and final series of injections. Under aseptic technique, approximately three injections were made into the region of the scalp with a total of 0.5 mL of Kenalog strengt h 4 mg/mL was used and injected into the region today. Postprocedural care and expectations were discussed with the patient. He voiced understanding. I have advised the patient that continued regrowth will occur over the next one to thre e years. Follow up at this point will be open-ended. Other than that the patie nt did inquire into hyperhidrosis treatment for the hands and feet. I have disc ussed the various methods of treatment in the office with the patient today as w ell as I have given him a handout for the sweathelp.org the webpage for the inte rnational hyperhidrosis society. The patient states he will gather more researc h and be back in touch with us with regards to the hyperhidrosis. He is also in terested in resurfacing of his skin via chemical peels. We will see him back fo r followup open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Actinic keratosis, right chest wall. This lesion was treated in the off ice today with liquid nitrogen cryotherapy x2 cycles. Postprocedural care and e xpectations were discussed with the patient. She tolerated the procedure well. I have advised the patient to keep watch over the area over the next couple of months. If she continues to notice any changes in texture, I would like for her to follow up before her six-month checkup for removal. 2. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. Additionally, I have written the patient for Tazorac 0.1% cream and have given her some samples prior to starting the tra de size tube. I have advised the patient to start on twice daily titrating up t o every other night and nightly use as tolerated. Side effect profile was discu ssed regarding the topical retinoids with the patient. She voiced understanding . 3. History of squamous cell carcinoma. We discussed monthly skin checks, l ooking for any new or changing pigmented lesions. We also asked the patient to look for an irregular border, asymmetry, change in color or increase in diameter

of any pigmented lesion. Today, I reviewed sun protection guidelines. I discus sed ABCD s and the use of sunscreen. I also recommended monthly self skin exam. The patient understands we should be notified for any changing lesions, new, or concerning lesions. I also discussed the use of wearing a hat and avoiding outd oor sun exposure at the peak sun hours. Follow up will be in approximately six months. We will reassess the effectiveness of the Tazorac at that time and do a n upper body skin exam in December. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Jacqueline presents to the office today for area of concern on the right lower leg, which she states has been somewhat itchy over the last two year s. She is allergic to Sulfa drug and has an allergy to some cheap jewelry. She is taking Zyrtec, Asmanex for asthma and allergies. She has a history of seaso nal allergies and has had hives in the past along with asthma. She is occasiona l drinker and nonsmoker who is not trying to get pregnant. The patient denies a ny personal history of skin cancers. She has a maternal grandfather that did ha ve a history of non-melanoma skin cancer. She admits to no blistering sunburns as a child and has used a tanning bed, but less than 20 times in her life. 1. Dermatofibroma, right lateral leg. The patient was reassured of the ben ign nature of this condition - no treatment is necessary. 2. Cherry hemangioma, right upper shoulder. I have removed this lesion tod ay as a courtesy to the patient with electrodesiccation. Under aseptic techniqu e, the hemangioma was anesthetized. The site was marked and confirmed with the patient, cleansed with alcohol, and infiltrated with lidocaine 1% with epinephri ne, 1:100,000 dilution as local anesthesia. It was then electrocauterize under the low setting of 18. Postprocedural care and expectations were discussed with the patient. She tolerated the procedure well. 3. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. Follow up will be on an open-ended basis. The patient has expressed desire to have a total skin exam in the future. I h ave recommended a total skin exam for the fall of 2012. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Mr. Brown presents today for suture removal on the posterior thigh. Pathology results, which come back consistent with dermatofibroma. The patien t denies any fever, sweats, chills, or any oozing bleeding, crusting, or drainag e from the wound site. ASSESSMENT/PLAN: The patient presents for suture removal. The patient has no c omplaints about the surgical site, and the wound has healed without any complica tion. The wound was cleansed and sutures were removed. The patient was instru cted to call me if there is any concern about the surgical site in the future. Pathology results were discussed in the office with the patient today. This was consistent with a dermatofibroma. No further treatment is necessary. Follow u p remains open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\patricia jill samples consolidated\06-13-12\061312_pjl.doc 7/28/2012 1:02: 25 PM 136704 SUBJECTIVE: Natalya presents today for followup of her dermatitis, not otherwis e specified, on the feet, rule out callus/xerosis versus tinea pedis versus plan tar warts. The patient states marked improvement from use of the urea cream twi ce daily over the last two weeks. She stills states she does have some resistan t hyperkeratotic spots on the plantar surface of the heels bilaterally. OBJECTIVE: Physical examination reveals a well-developed and well-nourished Afr ican-American female, in no apparent distress. On examination of the plantar as pects of the feet bilaterally, she still does have some persistent hyperkeratoti

c patches consistent with xerosis; however, the patient reports no itching. The re is no interdigital involvement noted at today s visit on either foot and there does not look to be any verrucous type of papules consistent with verruca plana. This looks to be purely xerosis and hyperkeratosis in nature. ASSESSMENT/PLAN: Dermatitis, not otherwise specified. The patient was examined by both myself and Dr. Robert J. Pariser in office today. He does also think t hat this is purely xerosis in nature at this time. At this time, we will contin ue on keratolytics to the affected areas twice daily. After that, she may conti nue on with heavy emollient moisturizers such as Cetaphil body cream and/or Cera Ve body cream with a 50:50 Vaseline mix. Follow up will be open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Mr. Sanderlin presents to the office today for a three-month checku p of his actinic keratoses. He states he does have a few on the dorsum of the a rms as well as on the face. He also does have area of concern on the nasal tip. The patient does have a history of basal cell carcinoma in the past. 1. Actinic keratoses. A 13 were treated in the office today with liquid ni trogen cryotherapy x2 cycles. Postprocedure care and expectations were discusse d. The patient tolerated the procedure well. 2. Neoplasm uncertain of the nasal tip. Rule out BCC versus SCC versus HDA K versus ISK. After obtaining written consent, the patient was prepped with alc ohol. Buffered Lidocaine with epinephrine 1% was administered for local anesthe sia. The lesion was removed in its entirety via a shave procedure with a Dermab lade. Drysol was used for hemostasis. Polysporin ointment was applied and the wound was bandaged. Wound care instructions were reviewed. The patient tolerat ed the procedure well. Pathology results will be mailed to the patient. 3. Seborrheic keratosis. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. 4. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 5. History of basal cell carcinoma. We discussed monthly skin checks, look ing for any new or changing pigmented lesions. We also asked the patient to loo k for an irregular border, asymmetry, change in color or increase in diameter of any pigmented lesion. Today I reviewed sun protection guidelines. I discussed ABCD s and the use of sunscreen. I also recommended monthly self skin exam. The pa tient understands we should be notified for any changing lesions, new, or concer ning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SOCIAL HISTORY: The patient is a nondrinker and nonsmoker, who has never been i n a tanning bed. He states he is on day 60 of 90-day course of Lamisil for his already diagnosed onychomycosis and tinea pedis. This was addressed and the tre atment was initiated at last date of service on 04/09/2012 by Dr. Cyndi Torosky. He states that while the betamethasone ointment used on the arms and legs has helped clear the rash somewhat he states he noticed that it still is continuing to be persistent after trial discontinuation of the betamethasone ointment. He states that the betamethasone ointment additionally has been quite expensive and states that he feels the triamcinolone one-pound jar that he has at home _____ good job when used twice daily as needed for flares. 1. Tinea pedis with onychomycosis. The patient was on day 60 of Lamisil. He will continue on for the remainder of the 90-day course with the final month of therapy and taking one 250 mg of Lamisil tablet daily. 2. Actinic keratoses of the left pinna. This lesion was treated in the off ice today with liquid nitrogen cryotherapy x2 cycles. Postprocedure care and ex pectations were discussed with the patient and he tolerated the procedure well. 3. Xerosis, likely asteatotic eczema in nature. Cannot rule out fungal inv olvement. The patient was seen by Dr. Alan Rolfe today in the office. He was a

dvised discontinuing the betamethasone dipropionate ointment and instead going w ith the triamcinolone ointment, which the patient may combine with clotrimazole twice daily over the next few weeks. If this combination is not effective in clearing up the rash on the tops of the arms and the legs, we would like to see him back in two weeks. Otherwise, the p atient will be keeping followup with Dr. Cyndi in four weeks for followup of his onychomycosis. With regards to the psoriasiform patches of dermatitis on the s calp, Dr. Rolfe has recommended at this time that the patient look into over-the -counter clinical strength dandruff shampoo such as Head & Shoulders, DHS, or ov er-the-counter Nizoral. The patient voiced understanding. Follow up at this ti me is open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. The patient gives a personal history of actinic keratosis, but no skin cancer. He is unsure of his family history of skin cancer. He states tanning bed use is a couple of times in his whole entire life. He does admit to blistering sunbur ns as a child. OBJECTIVE: On exam, he is a well-developed and well-nourished Caucasian male, i n no apparent distress. I did examine scalp, face, neck, trunk, and bilateral u pper and lower extremities including the buttocks and the genital region at toda y s visit. On examination of the sun exposed areas of the body, he has numerous l ight tan and light brown macules of various shapes and sizes consistent with sol ar lentigines. He also has some light tan and light brown warty waxy stuck-on a ppearing papules, flesh-colored to light brown in nature, consistent with seborr heic keratoses. On the trunk, he does have some symmetrical cherry red papules consistent with cherry hemangioma as well as one present on the right zygoma of the cheek, which was viewed under dermatoscopy today by both myself and Dr. Alan Rolfe in the office. On the vertex scalp, he does have two ill-defined erythem atous plaques consistent with actinic keratoses and on the penile shaft, there i s one verrucous papule on the dorsal aspect of the shaft consistent with condylo ma. He also does have two lentigines present on the penile shaft. The patient states he has had these for some amount of years and they have remained stable. He does have some fine flaking consistent with generalized xerosis of the feet. 1. Condyloma. One lesion was treated on the dorsum of the penile shaft wit h liquid nitrogen cryotherapy x3 cycles. Postprocedure care and expectations we re discussed with the patient. He tolerated the procedure well. 2. Actinic keratoses. Two on the vertex scalp were treated today in the of fice with liquid nitrogen cryotherapy x2 cycles. Postprocedure care and expecta tions were discussed with the patient. He tolerated the procedure well. 3. Lentigo. Both sun exposed regions and the dorsum of the penile shaft. I have asked the patient if he would like Dr. Rolfe to examine these under derma toscopy and the patient states that he would like for Dr. Rolfe to examine these at his next visit as he is pressed for time today. 4. Seborrheic keratoses. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. 5. Hemangioma. The benign nature of the lesions was discussed and no treat ment is necessary at this time. Additionally, Dr. Rolfe has consulted with the patient regarding the hemangioma on the right cheek and the patient wishes to ha ve this removed via electrodesiccation in the future with a fine needle tip. We will be happy to oblige. Dr. Rolfe has advised the patient that this may have a possibility of recurrence and the patient voiced understanding. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ALLERGIES: The patient is not allergic to anything that she knows of. She is n ot allergic to any medications that she knows of. OBJECTIVE: Physical examination reveals a well-developed and well-nourished His panic-American female, in no apparent distress. I did examine today the face, n eck, trunk, and bilateral upper extremities. On the right shoulder, she does ha ve approximately 9 mm hyperpigmented thickened papule, which dimples upon compre ssion, consistent with dermatofibroma. This was confirmed and viewed under derm

atoscopy by Dr. Alan E. Rolfe in office today. The patient has been advised tha t only if it becomes symptomatic would we need to do anything to it such as intr alesional injection to soften out the papules if it became somewhat bothersome. The patient states that it does not bother her at this point and she would rath er leave it alone. On examination of the face, she does have some open and clos ed comedones in the T-zone region of the forehead, nose, and chin along with som e inflammatory papules most notably on the bilateral malar cheeks region consist ent with both comedonal and inflammatory components of acne vulgaris. She also does have on the right great toe a 6-mm verrucous papule consistent with verruca . 1. Verruca, right great toe. This lesion was frozen in the office today wi th liquid nitrogen cryotherapy x3 cycles. Postprocedure care and expectations w ere discussed with the patient. She tolerated the procedure well. I have also advised her to continue on at home anywhere from three to seven times a week wit h the home wart treatment. Instructions were given to the patient today. She u nderstands that she may have to come in for a touchup with the liquid nitrogen e very four to six weeks one or two additional times after today. 2. Acne vulgaris with postinflammatory changes. Cheeks and chests are the main areas of involvement, especially with regards to the inflammatory papules. I have advised the patient continue on with her Proactiv wash. She is to take minocycline 45 mg extended release tablet one tablet p.o. q.d. and then at night she may apply a small pea sized amount of Epiduo to the face spreading into a t hin film starting on every other night titrating up to nightly use as tolerated. Side effects of all medications were discussed with the patient. She does und erstand. 3. Dermatofibroma, right shoulder. The patient was reassured of the benign nature of this condition--no treatment is necessary. Follow up will be in two months for reassessment of the acne regimen. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: On examination, he is a well-developed and well-nourished Caucasian male, in no apparent distress. I did examine the scalp, face, neck, trunk and b ilateral upper extremities today. On examination of the face and scalp, it is f ree and clear of anything, but some very mild flaking consistent with mild xeros is and seborrheic dermatitis. On examination of the scalp and face looked to be under good control with use of the desonide lotion, 2% ketoconazole shampoo use d when needed. On examination of the central forehead, he does have some erythe ma with a couple of ill-defined waxy plaques consistent with actinic keratoses, none of which are hyperkeratotic at this time and the patient wishes to defer in office cryotherapy and wait until the fall to choose whether or not he will be doing the Efudex topical therapy twice daily for two weeks or the Levulan Kerast ick PDT blue light therapy. He points to an area of concern on the central ches t. This is a warty waxy stuck-on appearing plaque, light brown colored in natur e consistent with seborrheic keratosis. It has recently arisen and causes no sy mptoms for the patient. 2. Actinic keratoses. The patient wishes to begin Efudex treatment or PDT treatment in the fall of 2012. 3. Seborrheic keratoses, central chest. I would like to monitor this at hi s fall followup. If it becomes bothersome to the patient, I may elect to freeze it at the three-month followup as a courtesy to the patient. Followup will be in three months, September or October of 2012. At that time, we will look into either writing the prescription for the Efudex cream or if he wishes we may elec t to do prior authorization for photodynamic therapy. This will be based on the patient s decision. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ASSESSMENT/PLAN: Follow up will be pending approval of ______is working on this paperwork currently and I have advised the patient that they will be contacting him once they hear a word back from his insurance agency. The patient understands and accepts the risks, benefits and alternatives associa

ted with the treatment. 1. Actinic keratoses. These were treated in office today with liquid nitro gen cryotherapy x2 cycles. Postprocedure care and expectations were discussed w ith the patient. She tolerated the procedure well. 2. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 3. History of BCC. We discussed monthly skin checks, looking for any new o r changing pigmented lesions. We also asked the patient to look for an irregula r border, asymmetry, change in color or increase in diameter of any pigmented le sion. Today I reviewed sun protection guidelines. I discussed ABCD s and the use of sunscreen. I also recommended monthly self skin exam. The patient understands we should be notified for any changing lesions, new, or concerning lesions. I a lso discussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours. Follow up will be of her next total skin exam already scheduled with Dr. Molly K. Smith. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Kathleen presents to the office today to renew her Retin-A 0.04% mi cros prescription. She also states that she is looking for a sunscreen that wil l not breakout within 24 hours of applying the Retin-A. The patient uses the Re tin-A for her acne, which she states is under good control since using the Retin -A. She states her main breakouts occur on the chin when they do happen and she does use CeraVe PM for the dry patches on the face which occur often times seco ndary to use of the retinoid therapy. She also is in today for information on c osmetic removal of lentigo. MEDICATIONS: The patient is only using Retin-A topicals her daily medications. ASSESSMENT/PLAN: Acne vulgaris and postinflammatory changes. I have refilled h er Retina-A 0.04% micro and reviewed the side effect profile of the topical reti noid with the patient in office today. She understands. For the xerosis, she w ill continue to use the CeraVe PM on the face as needed for dryness. With regar ds to the solar cosmetic laser removal for the lentigines, we have discussed bot h _____ and IPL laser. I have advised her to consult with either Dr. Cyndi Toro sky or Dr. Lawrence Chang for a consult to discuss pricing of the areas of conce rn. The patient has taken the information for both doctors, we will further res earch the matter and we will get with one of them for cosmetic removal of her le ntigo. Follow up with this office will remain open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Jane presents to the office today for eczema which the patient stat es she has had all her life. It has bothered her particularly over the last mon th as she states she has had some stressful family issues, which she believes ha ve directly contributed to the flare up. The patient gives no other history of skin problems and no family history of skin problems. PAST MEDICAL HISTORY: The patient gives a past medical history of allergies, ec zema, high blood pressure, diabetes, as well as arthritis. 1. Dermatitis, not otherwise specified. This looks to be atopic flare up exace rbated by stress. We are going to increase the strength of her steroid and have her discontinue the mometasone, instead continuing on with clobetasol ointment. I have written her for 60 g tube with two refills. She is to apply those to t he affected areas of the arms, legs and the chest twice daily over the next few weeks avoiding the face and any delicate skin areas. For the psoriasiform patch es on the scalp, I have written her for 100 g can of the clobetasol foam, I thin k as above she had the Olux-E foam, she can apply this once or twice daily to th e affected areas of the scalp for itch relief. For the face, I have prescribed her desonide ointments which she may use twice daily to the affected areas of th e face as needed for flares. I have written her for 30 g tube. For itch at nig ht, I have prescribed Periactin 4 mg tablets she may take one tablet p.o. p.r.n itch q. 4-6 hours. I have written her for #30 with one refill. For non-drowsy

daytime itch relief she may opt to use the Allegra 180 mg over-the-counter table ts. I have advised the patient to continue on the with Cetaphil cream, however, I would like her to switch out to an unscented wash such as Dove for sensitive skin and also try unscented laundry detergent such as all free and clear. These are given to the patient in office today, samples as well as coupons. 2.. Lentigo. The patient was reassured regarding the benign nature of these le sions. These lesions do, however, indicate diffuse sun damage. We discussed th e importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater wh enever they are exposed to the sun. Follow up in two weeks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. On the nasal tip, there is a calcified papule consistent with milia. No sig ns of malignancy present today on the nasal tip. This was confirmed and viewed under dermoscopy by Dr. Alan Rolfe. She has advised that if patient wishes to t ake care of this should it grow in size she may wish to have this done via elect rodesiccation with a fine-needle tip. With regard to the area on the left chest , this is a warty waxy stuck-on appearing papule consistent with seborrheic kera tosis. On the margin of the left lower eyelid, there is a 2-3 mm flesh colored papule that actually looks to be two 2 mm papules directly adjacent to each othe r, which when viewed under dermoscopy by Alan Rolfe look to be a possible benign eccrine hidrocystoma versus sebaceous hyperplasia, but cannot rule out in the d ifferential sebaceous carcinoma versus basal cell carcinoma. He would like to g ive the area approximately two months to see either one of the two growths conti nue to grow or become pinkish color in nature. At that point if they do, he wou ld tend to lean for the diagnosis more suspicious for cancer. The patient state s that they have remained stable over the last few months and have not grown. S he states she has had them for approximately six months. He has discussed with the patient that she may opt have them removed in the office via dermatologic su rgeon or she may opt to have her ophthalmologist remove them. It will be up to her. Dr. Rolfe stated that he would like to follow up with her in approximately two months to see if there has been any change in size or color. She does have some mild telangiectatic rosacea. No inflammatory papules are seen today; howe ver the patient does state that she has had an element of papular rosacea as wel l. She states that the Finacea keeps the papules under decent control, but she would like treatment for the telangiectatic component. I have given the patient the information for Dr. Cyndi Torosky and Dr. Lawrence Chang and have advised h er that they do a dye/light laser for vascular lesions. The patient states she will follow up with them for further treatment of the cosmetic laser treatment f or her telangiectatic rosacea. Follow up otherwise will be in two months with D r. Alan Rolfe for a recheck on the eccrine hidrocystoma of the left lower eyelid margin. If any growth 2. Milia on the nasal tip. The patient was informed of the benign nature of th is condition. Unless it should grow we will continue to monitor. Otherwise, if it becomes larger and cumbersome to the patient, we will be happy to remove via electrodesiccation with fine tip needle. 3. Seborrheic keratosis. The patient was informed of the benign nature of thes e lesions and no treatment is necessary at this time. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Johanna presents to the office today for Botox axillary for her hyp erhidrosis. The patient states she was treated back in October of 2011 and bega n breakthrough right around the holiday period. She states she was then busy ov er the holidays and was unable to contact the office for reinitiation of orderin g the Botox for hyperhidrosis. When she was able to get the vial re-ordered the y had informed her that she was only eligible for one vial at that time. As the patient has only experienced approximately 2.5 months to 3 months of being swea t free, I am going to initiate preauthorization for the next visit for two 100 u nits vials if at all possible. The lot number for the values today is C3025-C3, expiration date 11/2014. The patient denies pregnancy at this visit. She is n ot currently on any medications nor is she is allergic to any medications. She

denies any personal or family history of multiple sclerosis at today s office visi t. She is a rare drinker and nonsmoker. ASSESSMENT/PLAN: Hyperhidrosis. Botox for axillary hyperhidrosis. The bilater al axillary vaults were cleaned today with sterile alcohol swabs with 50 units i njected into the right axillary vault and 50 units injected into the left axilla ry vault. The patient tolerated the procedure well with minimal bleeding and br uising. Postprocedure care and expectations were discussed with the patient. S he understands. I have sent in request to do prior authorization for two 100 un its vials for the next appointment as the patient is getting slightly less than three months of sweat free time with the one 100 unit vial of Botox. The risks and benefits of treatment were discussed and consent for Botox was signed by the patient as well as myself. Risks of treatment include a vasovagal response, (i ncluding flushing, faint feeling, sweating and nausea/vomiting), brow droop or e yelid ptosis, headache and bruising. Corrective effects (decreased movement) ar e usually noticed 3 days after treatment. The full effect of treatment is seen at 1-3 weeks. The patient was instructed not to lay down or bend forward for pr olonged periods during the first few hours after treatment to avoid the risk of drug migration. A copy of the FDA Medication Guide regarding potential risks wa s provided. Specifically, the risks of potential severe neurologic effects were discussed. However, we stressed that these effects have not been reported with the appropriate dosing/administration of Cosmetic Botox or its use for hyperhid rosis. All questions were answered for the patient and consent for Botox form wa s signed. Follow up will be pending breakthrough sweating. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: On exam, she is a well-developed well-nourished Caucasian female, in no apparent distress. I did have the patch test removed in office today by der matology assistant, Amanda Moore. I then let the patient sit on the exam table for a period of 10 minutes. The paneled areas were then re-marked and the templ ets were read with the following reagents having a 1+ reaction: Nickel sulphate (reagent #1), Caine mix (reagent #5), quarternium 15 (reagent #18), and tixocort ol 21-pivalate (reagent #28). Again all of these were 1+ reactions. This is a mild erythema with slight induration. No vesiculation present. I have advised the patient. She will be following up in approximately 24 hours with Lindsay Tu rner, PAC for her delayed patch test read. At that time, a treatment plan will be tailored to the patient based on these results and any results of the delayed hypersensitivity read. Follow up in 24 hours. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Jordan presents to the office today for some _____ rash and peeling that he has had over the last three weeks. Of note, he did have a strep infect ion two months ago, strep throat. This started approximately six weeks after th e end of the strep throat. The patient s mother who accompanies him today in offi ce does admit to an extensive history since he was a baby of eczema. He has als o had extremely dry skin for some amount of time treated very occasionally with topical steroids. Mostly, she uses Ivory soap for cleansing and they rub vitami n E capsules on the child as well as cocoa butter. She does not like to do the topical steroid as she is concerned about the side effects. She states that the eczema gets worse every spring going into the summer. OBJECTIVE: On exam, he is a well-developed well-nourished African-American male , in no apparent distress. I did examine today the scalp, face, neck, trunk, an d bilateral upper and lower extremities. On examination, the patient is extreme ly dry. He does have fine flaking throughout the trunk and bilateral upper and lower extremities with some ichthyosis present on the tibial aspect of the lower extremities bilaterally. He also has some perifollicular accentuation on the k nees and elbows consistent with the papular type atopic dermatitis or papular ty pe eczema and lichen nitidus. There is also some hyperpigmentation and lichenif ication present most notably in elbows and knees as well, also consistent with h is atopic dermatitis. ASSESSMENT/PLAN: Atopic dermatitis with generalized xerosis. I have advised th

e patient s mother to discontinue the Ivory soap as well as the vitamin E capsules and nut butters as the fragrance may be further exacerbating the problem. Addi tionally, she states she is using Tide detergent. I have advised her to switch to all free clear detergent. In place of the Ivory soap, I have given them samp les of the Dove for sensitive skin body wash and Cetaphil lotion and Cetaphil cl eansers. She may opt to use this or CeraVe for his wash over the next two weeks . Instead of vitamin E capsules and nut butters, I have advised her to try Ceta phil heavy cream. I have given her samples as well as coupons in office today. She may opt to mix this with the 50:50 mixture of Vaseline and apply to the chi ld at least two to four times daily. For the areas of dryness and desquamation and thickening present on the hands, elbows, and knees I am going to write her f or triamcinolone 0.1%. She may use this twice daily to these areas as needed fo r flares and I have advised children s Allegra for a non-drowsy daytime itch relie f and children's Benadryl at night. Follow up will be in approximately six week s. We will be most of the way through the summer at that time. I have advised the patient of course if he does not improve over the next week to two weeks signifi cantly, then I would like to see them back before the six-week followup. The pa tient and mother voiced understanding. Approximately 20 minutes was spent in of fice counseling both the patient and mother on the importance of short tepid sho wers or baths spaced out every couple of days if the patient is not dirty. We s witched to Tide and then we switched to Dove all that stuff and that was what 20 minutes was spent in office going over that and a detailed treatment plan writt en up for the patient and mother to refer to in the event they had questions. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Elma presents today for rash on her arm she has had over the last f ew weeks. She has used Benadryl and calamine on it. She does state a history o f her skin reacting to perfume. She is currently taking enalapril and Lovaza. She has been taking these for some months now with no ill effects. The patient gives a past medical history of allergies, high blood pressure, and eczema. She is a nondrinker and nonsmoker. When I took the history from the patient, she s tates that she does do an extensive amount of gardening work. She also states t hat she has an area of dermatitis on the mouth that has been bothering her as of late. The patient states that she loves eating cinnamon oatmeal along with cin namon gums and mints. Cinnamon tea and also mint tea. She also does admit to a n extensive amount of gardening work. OBJECTIVE: On exam, she is a well-developed, well-nourished Filipino-American f emale, in no apparent distress. I did examine today the scalp, face, neck, trun k, and bilateral upper extremities. On the sun exposed areas of the upper body, she has numerous light-tan, light-brown macules in various shapes and sizes con sistent with solar lentigo. On the mouth, she does have erythematous patch on t he mid upper cutaneous lip, which looks to be consistent with irritant or allerg ic contact dermatitis. Also, she has some spongiotic appearing nummular shaped patches on the dorsum of the forearms bilaterally what looks to be allergic cont act dermatitis in nature. It is somewhat photodistributed, which means that pol ymorphous light eruption cannot be excluded from the deferential; however, this does look to be more contact in nature and given her history of garden work and reactions to heavy fragrances, it further supports this suspicion. The patient uses Dove soap, Tide detergent, and Avon cocoa butter, and olive oil moisturizer s. She also uses aloe vera moisturizer as well. ASSESSMENT/PLAN: Dermatitis, not otherwise specified, likely allergic contact d ermatitis in nature and they are also on the differential must be an irritant co ntact dermatitis versus polymorphous light eruption versus possible drug eruptio n. For the mouth, I have given the patient ketoconazole cream, which I would li ke for her to use, applied to the affected perioral region q.a.m. and at night s he will do desonide cream to the perioral area. For the arms, I have given her Lotrisone cream, which I would like for her to use on the areas of the arms twic e daily and then I would like to see her back in approximately two weeks for fol lowup. I have given her 30 Atarax 25 mg tablet she may take one to two at night

p.r.n. itch. I have advised Allegra 180 mg tablet for a non-drowsy itch relief alternative during the day. I have advised her to discontinue all scented soap s and cleansers to include Dial and Tide as well as the nut butter creams instea d I have given her samples of Cetaphil Restoraderm and coupons so she may obtain this at her local drug store or pharmacy. I have also given her some samples of the all free and clear to use in place of the Tide and she would like to purchase Tide free and clear as well. Approximat ely, 20 minutes were spent in the office with the patient today discussing atopi c skin care therapy. Personalized regimen was developed for the patient as well . We will follow up in two weeks. If no improvement is noted at that time, the n further diagnostic testing maybe warranted such as biopsy and/or patch test pl acement in the future. SUBJECTIVE: Kimberly presents to the office today for options for her hidradeni tis suppurativa. She had an excellent response to the Humira therapy and then h er insurance suddenly stopped approving it. At that time, she had gone into hav ing very painful recurrent flare ups of her hidradenitis suppurativa, most notab ly in the bilateral axillary vaults and the inframammary region. She has had nu merous treatments before and has responded well to doxycycline in the past. How ever, the patient is currently on dapsone and states she does not like it. She states she is getting pain along the right upper thigh even since she has been t aking it and wishes to discontinue it at this time for possible patient assistan ce program, which may or does offer to a selective group of patients. ASSESSMENT/PLAN: Hidradenitis suppurativa of the submammary skin and inguinal f olds have previous excellent response to Humira. The Abbott Assistance Program paperwork was filled out today in office by the patient and will be initiated by our dermatology assistant, Allie Bailey to see if shy may qualify for the Avent is Patient Assistance Program where she would receive the Humira at no charge. In the meantime, she is going to discontinue the Dapsone and the patient stated she would like to restart the doxycycline. She stated that she has been denied for the Doryx 150. I have advised the patient we can give the doxycycline 100 m g capsules twice daily. The patient is willing to do this and states no ill sid e effects after having taking doxycycline in the past. I have written her for a 90-day supply doxycycline 100 mg capsules to take one cap p.o. b.i.d. I have w ritten her again for 60 caps with two refills that should get her through the ne xt 90 days while we are waiting _____. I have advised the patient that Allie wi ll be calling Kimberly on next Tuesdays to give her an update. Kimberly can be reached at her house phone of 757-390-4677. She also left a cell phone contact at 757-919-5802. We will be in contact at that time. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. He was referred to us by Patient First. They had given him initially a six-day prednisone taper some weeks ago then they realized it was not a long enough tape r. They had added 12 days on to the taper. The patient states he continues to improve each day, but states that he continues to have what he believes is newer lesions pop up and is concerned that this will be persistent. He is currently not using any topical steroids and is done with his course of oral steroids. OBJECTIVE: Physical examination reveals a well-developed, well-nourished Filipi no male, in no apparent distress, accompanied by his mother in office today. I did examine today the face, neck, trunk, and bilateral upper and lower extremiti es. On examination, he does have some scattered benign symmetrical nevi, 2-3 mm in size, medium brown, well-circumscribed, and evenly pigmented. He also has o n the dorsum on the forearms as well as on the posterior and anterior aspects of the lower extremities and the abdomen and then back extensive spongiotic appear ing papules mostly in a linear form consistent with allergic contact dermatitis secondary to poison ivy contact. The patient gives a history of sports and doin g lots of yard work. It seems he is continuing to be inoculated from this poiso n ivy, but states that he is off sports practice for one week and has been more cognizant about the removal and laundering of his yard work wear. He also does have a couple of spongiotic green papules on the top of the forehead in linear f ashion as well also consistent with allergic contact dermatitis.

ASSESSMENT/PLAN: Allergic contact dermatitis with xerosis, looks to be improvin g since use of the oral prednisone taper. We will continue on topical steroid t reatment for now. I have written the patient for Clobex spray to be applied onl y to the affected areas, which are itching and then stop using once the itching symptoms have abated. I have written him for 125 mL bottle and would like for h im to use this twice daily over the next two weeks p.r.n. flares. The patient i s to use this for more than two weeks. He needs to return to the office at once . For the face, so I have given him a lighter strength steroid. He is to use t he Cloderm 30 g pump half pump to one pump to the face as needed twice daily for flares. Side effects to the steroids topically were discussed with the patient and his mother to include skin thinning, atrophy, and overuse. They voiced und erstanding. He has been taking two Benadryl twice daily. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Benign nevi left earlobe. Dr. Rolfe has advised the patient that this i s benign appearing in nature and unless it becomes cumbersome or irritating to t he patient, it does not warrant removal today in office. If it does become symp tomatic to the patient, he is happy to remove this surgically for her. 2. Verruca of the right hand palmar aspect of the right index finger. This was treated in office today with liquid nitrogen cryotherapy x3 cycles. Postpr ocedure care and expectations were discussed with the patient. She tolerated th e procedure well. 3. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. Follow up will be open ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. FAMILY HISTORY: The patient admits no family history of skin cancer, but does a dmit to blistering sunburns as a child. 1. Milia on the left jaw. The patient states she is going to go to an esth etician to have these extracted. 2. Irritated seborrheic keratosis, left hip. Freeze was done of this lesio n with liquid nitrogen cryotherapy x3 cycles. Postprocedural care and expectati ons were discussed with the patient. She tolerated the procedure well. I have advised the patient due to thickness of this lesion she may need to come in for reoccurrence. Again, I have no problem during this as a courtesy to the patient . 3. Seborrheic keratosis on the scalp. The patient was informed of the beni gn nature of these lesions and no treatment is necessary at this time. 4. Actinic keratosis, left upper arm. One lesion was frozen today in offic e with liquid nitrogen cryotherapy x2 cycles. Postprocedural care and expectati ons were discussed with the patient. She tolerated the procedure well. 5. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. Also the patient did want me to examine the genital region. On the external lab ia, she did have some inflammation in the form of mild erythema. She is looking to get her annual GYN exam on June 27th. She has currently been using Nystatin , but states that it is still somewhat inflamed. I have given the patient a 30 g tube of desonide cream to help with inflammation until she is able to meet up with her gynecologist on 06/27/12. She may use this twice daily over the next t wo weeks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ASSESSMENT/PLAN: Pityriasis alba. I have advised the patient and mother that t his is sometimes correlated with eczema and allergies. There is not much that c an help with the repigmentation. However, diligent sunscreen use is indicated t o further prevent the non-lightened patches from becoming darker and accentuatin

g the pityriasis alba patches. The patient and mother voiced understanding. If it does become inflamed or symptomatic which the patient states it currently is not, she may opt to do a hydrocortisone 1% cream for a period of three to seven days to the area to see if that will help calm down the inflammation. Otherwis e, general skin care is indicated such as Cetaphil cream and/or CeraVe cream. I have given the patient some samples of over-the-counter sun block to include Ne utrogena SPF 50 and some Cetaphil lotion and CeraVe lotions. I have advised dis continuing scented lotions to the face as that may only further aggravate the si tuation. Follow up at this time will be open ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Micha presents to the office today for followup of his acne therapy . He still continues to have some persistent postinflammatory changes with his inflammatory acne. He states while the Epiduo has helped somewhat he states tha t he would like to see more progress, but states he does not wish to do Accutane at this time yet. He states he has only been using the doxycycline once daily as that is how he thought he was supposed to use this. Upon retrieving my notes from last date of service 04/11/2012, I had reiterated to Micha that I had pres cribed the doxycycline 100 mg capsules to be dosed at one tablet by mouth twice daily. The patient understands and will move up to twice daily dosing of the do xycycline. ASSESSMENT/PLAN: Acne vulgaris with postinflammatory changes and both cystic an d inflammatory components as well as a comedonal component. I have stressed com pliance to the patient s in correct dosing of all medications. He states he will be taking the doxycycline twice daily and I have advised him this is going to be critical over the next two months to see if this will indeed calm down the post inflammatory erythema. If he is taking it as directed and he is not improving i n two to three months pending p.r.n. approval, we may opt to go to Accutane ther apy at that time. For now, he will continue on with his Neutrogena acne cleanse r for morning wash and I am increasing the strength of his retinoid today from E piduo to Tazorac 0.1% gel. He is to apply a pea size amount of this to the face starting on every other night titrating up to nightly as tolerated. He may use CeraVe PM and/or another oil free moisturizer afterwards to help with dryness a nd irritation this may cause. He states he is using Clearasil over-the-counter moisturizer with good results. I have advised him that he may continue on with this one if he so wishes. Follow up will be in two months. At that time, we wi ll reassess the correct doses of the doxycycline therapy and see if triple thera py would be enough to control his inflammatory acne. If not, we will move to Ac cutane therapy at that time. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\patricia jill samples consolidated\06-14-12\061412 pjl-2.doc 7/28/2012 1:0 2:27 PM 89088 SUBJECTIVE: Pamela presents to the office today for a followup on her Botox as well as an established patient for total skin exam. She states that she is noti cing some numerous moles come up on the chest and back, which she suspects are h ereditary and she would like these examined today. The patient had a particular ly deep furrow in the glabellar region, which she states has smoothed out comple tely with the use of the Botox. She is pleased with treatments, but would like a reevaluation at today s visit to see if there are any additional touch ups neede d. OBJECTIVE: On examination, she is a well-developed, well-nourished African Amer ican female, in no apparent distress. On examination today, the glabellar and f rontalis region do appear smooth even despite requests for dynamic movements suc h as scaling and looking surprised. The Botox has done excellent job of smoothi ng out her static and dynamic rhytides formally present back on last date of ser vice 05/02/12. On examination of the scalp, face, neck, trunk, and bilateral up per and lower extremities, she does have some patchy hyperpigmentation present i

n the neck and jawline area. She states she has noticed also some textural chan ges on the chest, abdomen, and back. On examination here, she does have some fl eshy pedunculated dark-brown growths consistent with benign nevi. They are well -circumscribed and evenly pigmented. A couple are present on the face as well c onsistent with dermatosis papulosa nigricans. On the left hip, she does point t o a thickened hyperpigmented papule which dimples upon compression consistent wi th dermatofibroma. The patient does give a history of insect bite in that area previously. 1. Dermatosis papulosa nigricans. I have informed the patient the benign n ature of this condition and no treatment is necessary. 2. Dermatofibroma of the left hip. The patient was reassured of the benign nature of this condition - no treatment is necessary. 3. Hyperpigmentation of the neck and a couple of areas on the legs. I have discussed with the patient that hyperpigmentation is often very hard to resolve . I have given her some samples of the Aclaro hydroquinone 4% cream to use nigh tly a small amount to the darkened areas to see if this will help with lightenin g of the areas. I have recommended Ambi Fade hydroquinone 2% cream over-the-cou nter. Additionally, she is using Rx for brown skin and has just started using t his line approximately three weeks ago with a notable improvement in the face an d some improvement on the neck over the last three weeks. I have told the patie nt if it does contain either retinol or retinaldehyde and/or hydroquinone that t hese are suitable for her skin and we would not need to do additional prescripti on strength retinols or hydroquinone if she is already using this in her Rx for brown skin care line. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Laura presents to the office today for some milia on the face and a n itchy mole on the back and excessive underarm sweating. She states the milia on the face are tiny, but she is very bothered by them as they look to be whiteh eads in nature. Her primary care doctor had recommended dermatologist for extra ction. The itchy mole on the back she has recently discovered over the last yea r. With regards to the underarm sweating, she states she has had excessive swea ting since 13. No bromhidrosis noted, but just excessive amounts of sweating, w hich have led the patient to use only dark clothing. She is unable to wear colo red shirts as she continues to sweat profusely through the colored shirts leadin g to extremely embarrassing situation socially. This is despite use of clinical strength secret, clinical strength Mitchum, and clinical strength Dove deodoran ts. She does give a history on her paternal grandmother of melanoma and states that her mother has rosacea. She is currently on Prilosec OTC, folic acid, B12 sublingual, and a multivitamin. The surgical history is significant for gastric bypass, cholecystectomy, and duodenum perforation repair. She also has anemia, beta thalassemia minor. She is a social drinker and nonsmoker. She used a tan ning bed approximately three summers in a row a few years go greater than 20 tim es in her life she does admit. No blistering or sunburns as a child. 1. Facial milia. Two warts extracted today via comedone extractor under as eptic technique, a #30 gauge needle was used to roof the milia one on the left c heek, one of the right cheek, and then they were extracted using comedone extrac tor. Postprocedural care and expectations were discussed with the patient. She tolerated the procedure well. 3. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 4. Seborrheic keratosis. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. 5. Telangiectasias. I explained to the patient the benign nature of this c ondition and discussed options for cosmetic treatment. No treatment was perform ed during today's visit. 6. Hyperhidrosis. The patient was given a prescription today for a Drysol to be applied to the axillary vaults nightly. We will have her follow up in fou

r weeks to discuss her success with the Drysol. Follow up in four weeks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Dermatofibroma, right shoulder. The patient was reassured of the benign nature of this condition-no treatment is necessary. 2. Skin tag. The patient was informed of the benign nature of these lesion s and no treatment is necessary at this time. 3. Benign nevi. All nevi are well marginated, homogenously pigmented, symm etrical, benign appearing moles. We reviewed ABCDs of melanoma. The patient wi ll monitor moles for any change or growth. The patient understands if any of th ese lesions begin to change, they are to return to clinic for reevaluation. 4. History of malignant melanoma, T4N2MO, diagnosed in 2006. No sign of re sidual tumor noted today on examination of the left neck and no regional lymphad enopathy noted as well. We discussed monthly skin checks, looking for any new o r changing pigmented lesions. We also asked the patient to look for an irregula r border, asymmetry, change in color or increase in diameter of any pigmented le sion. Today I reviewed sun protection guidelines. I discussed ABCD s and the use of sunscreen. I also recommended monthly self skin exam. The patient understand s we should be notified for any changing lesions, new, or concerning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours. We will see Mr. Thomas back in approximately six months for hi s next skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Dermatitis, not otherwise specified. The patient may continue on with k etoconazole as needed for flare ups during this summer. Because it is getting w orse with moisture, I have advised Zeasorb excess moisture powder, which she may purchase over-the-counter. She may apply this after the shower. If she wishes , she may also continue on with the ketoconazole use twice daily to help keep ye ast and fungus overgrowth at bay. 3. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. The patient will follow up in May of 2012 for her next total skin exam unless she needs it sooner. SUBJECTIVE: Megan presents to the office today for acne as well as spots on her right leg and her upper back. She states she has had the spot on the right leg for the last three to four years. She states that it has only bled when nicked by the razor and has remained stable, has not grown and has never been symptoma tic with regards to itch, pain, or spontaneous bleeding. She does give a histor y of her father having extensive sun exposure though she is unsure if he has had any cancers skin wise. She has no personal history of skin cancer, but does ad mit to blistering sunburns as a kid. She used a tanning bed one time in her lif e. She is currently also wondering about some acneiform eruption she has had, s pecifically on the jawline and neck region. She states these are inflammatory r ed papules that are difficult to surface and are often very bothersome to her wi th regards to appearance. The patient is allergic to sulfa drugs, penicillin, a nd codeine. She states she is not currently taking any daily medications. She gives a history of irritable bowel syndrome. She is an occasional drinker and n onsmoker. The patient denies any personal or family history of eczema or psoria sis as well. 1. Acne vulgaris with postinflammatory changes. I am going to start the pa tient on a pea-size amount of Differin 0.1% lotion applied to the face nightly t o help with the comedonal component of her acne. I would also like for her to d o a 90-day trial of the Doryx enteric-coated extended release doxycycline. She may take one tablet p.o. q.d. for the next 90 days. Side effects of the Doryx t o include photosensitivity and gastric episode were discussed with the patient. She has been advised that if she cannot tolerate due to gastrointestinal upset, she is to immediately discontinue the medication and call the office at once. Side effects of the retinoid therapy were also discussed with the patient. She

understands that she may need to use nighttime moisturizer to help offset the dr yness and irritation that the Differin 0.1% lotion may provide. I have advised her to start use of the lotion on Mondays and Friday titrating up to every other night use and then nightly use only if tolerated. 2. Neoplasm, uncertain of the medial aspect of the right lower extremity, r ule out irritated seborrheic keratosis versus basal cell carcinoma versus squamo us cell carcinoma. This dime-sized lesion was removed today using a shave techn ique. After obtaining a written consent, the patient was prepped with alcohol. Buffered lidocaine with epinephrine 1% was administered for local anesthesia. The lesion was biopsied via a shave technique using a Dermablade. Drysol was us ed for hemostasis. Polysporin ointment was applied to the wound and covered wit h a bandage. Wound care was reviewed. The patient tolerated the procedure well . Pathology results will be mailed to the patient. I have advised the patient that pathology will take approximately two weeks to be returned. The patient to lerated the procedure well. 3. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 4. Hemangioma. The benign nature of the lesions was discussed and no treat ment is necessary at this time. Follow up with me in two months for acne follow up unless we need to followup with the patient sooner based on her pathology res ults. 1. Actinic keratoses. One on the nasal tip, three on the right cheek, six on the left cheek, 10 total were treated in the office today with liquid nitroge n cryotherapy. Postprocedural care and expectations were discussed with the pat ient. He tolerated the procedure well. 2. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 3. Telangiectasia. I explained to the patient the benign nature of this co ndition and discussed options for cosmetic treatment. No treatment was performe d during today's visit. 4. History of basal cell carcinoma from the forehead and right preauricular region with well-healed scars. No sign of residual tumor noticed throughout. We discussed monthly skin checks, looking for any new or changing pigmented lesi ons. We also asked the patient to look for an irregular border, asymmetry, chan ge in color or increase in diameter of any pigmented lesion. Today I reviewed s un protection guidelines. I discussed ABCD s and the use of sunscreen. I also rec ommended monthly self skin exam. The patient understands we should be notified f or any changing lesions, new, or concerning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours. We will see Mr. Ayers in approximately six months for another upper body skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: On examination today, he is a well-developed, well-nourished African -American male, in no apparent distress. Physical examination of the lower extr emities bilaterally reveals some hyperpigmented patches which are flattened in n ature and markedly improved since last date of service 05/03/2012. These were p rurigo nodules, but have flattened out and softened considerably. All that rema ins is some postinflammatory hyperpigmentation. One is present on the left late ral leg, one on the left knee, one on the posterior calf, and three on the right tibial surface of the right lower extremity. He also points to a couple of hyp erpigmented scaly areas on the base of the neck, which looks to be consistent wi th tinea versicolor. The patient states he has had this in the past and has tak en pills for it. This looks to be mild involvement I think we can treat topical ly with antifungal shampoo at this time. 1. Lichen simplex chronicus/prurigo nodularis, treated successfully with Co rdran tape. I have advised the patient that he no longer needs to use the tape

at this time and only as needed for flare ups. I have written him for a refill in the event he does have any flare ups. For now, he can just continue on with a good emollient moisturizer. The patient has inquired into the postinflammator y changes and the residual hyperpigmentation as to whether or not anything can b e done about this. I have given him the name of the Ambi Fade cream, hydroquino ne 2%, and asked him to inquire about this to his pharmacist. He may obtain thi s anywhere from $20 to $30 over-the-counter. If he doses nightly for a period o f two months to the dark spots and notes no significant improvement, we may opt to do hydroquinone 4% via prescription. 2. Tinea versicolor, base of the right neck involvement at this point. I h ave given the patient a prescription for ketoconazole shampoo. I would like for him to apply this as a body wash and scalp soaking shampoo in the shower, leave on 5 minutes and then rinse for a period of two weeks then go down to twice a w eek for maintenance to keep yeast and fungal overgrowth at bay. I have advised the patient after two weeks this should take care of the itching and flaking sym ptoms of the tinea versicolor; however, the hyperpigmentation may take the entir e summer to resolve and even out. The patient voiced understanding. We will se e him back in three months to recheck the status of the tinea as well as do a fo llowup for his lichen simplex chronicus. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Brian presents to the office today for removal of an area on the ri ght central chest, rule out irritated seborrheic keratosis versus AN versus DN v ersus MM. He is also in today for freezing of actinic keratosis and this was pr esent on the right forehead at last date of service 05/10/2012. The patient had been on vacation to Cayman Islands. Says he has come back in today for treatme nt of these two areas. He is also in today for lentigo concerned on the left na sal sidewall. 1. Neoplasm uncertain right central chest rule out AN versus DN versus MM v ersus ISK. After obtaining a written consent, the patient was prepped with alco hol. Buffered lidocaine with epinephrine 1% was administered for local anesthes ia. The lesion was biopsied via a shave technique using a DermaBlade. Drysol w as used for hemostasis. Polysporin ointment was applied to the wound and covere d with a bandage. Wound care was reviewed. The patient tolerated the procedure well. Pathology results will be mailed to the patient. 2. Lentigo, left nasal sidewall. This lesion was treated as a courtesy to the patient with liquid nitrogen cryotherapy x2 cycles. Postprocedure care and expectations were discussed with the patient. He tolerated the procedure well. 3. Actinic keratosis on the right forehead. This lesion was treated with l iquid nitrogen cryotherapy x2 cycles. Postprocedure care and expectations were discussed with the patient. He tolerated the procedure well. Follow up will be in 05/2013 for his total skin exam, otherwise follow up will be pending patholo gy results. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Actinic keratoses. Two were treated in the office today with liquid nit rogen cryotherapy x2 cycles, one on the volar aspect of the left forearm and one on the dorsal aspect of the left forearm. Postprocedural care and expectations were discussed with the patient. He tolerated the procedure well. 2. Lentigines. The patient was reassured regarding the benign nature of th ese lesions. These lesions do, however, indicate diffuse sun damage. We discus sed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or grea ter whenever they are exposed to the sun. 4. History of non-melanoma skin cancer. We discussed monthly skin checks, looking for any new or changing pigmented lesions. We also asked the patient to look for an irregular border, asymmetry, change in color or increase in diamete r of any pigmented lesion. Today I reviewed sun protection guidelines. I discus sed ABCD s and the use of sunscreen. I also recommended monthly self skin exam. Th e patient understands we should be notified for any changing lesions, new, or co ncerning lesions. I also discussed the use of wearing a hat and avoiding outdoor

sun exposure at the peak sun hours. The patient follows up yearly for a total skin exam with Dr. Alan Rolfe, follow up will be at that time. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Laura presents to the office today for a growth on the forehead of _____. The patient has a history of non-melanoma skin cancer removed in the pas t on the nose, forehead, and back. She states she has had it over the last year and it has caused pain and bleeding. She has used Efudex in the past for some actinic keratosis treatment. She does have medication allergy to sulfa. She is currently taking Diovan HCTZ, simvastatin, and ____. She is occasional drinker and nonsmoker. 1. Neoplasm uncertain, left forehead rule out hemangioma versus _____ versu s BCC versus SCC. After obtaining written consent, the patient was prepped with alcohol. Buffered lidocaine with epinephrine 1% was administered for local ane sthesia. The lesion was removed in its entirety via a shave procedure with a De rmablade. Drysol was used for hemostasis. Polysporin ointment was applied and the wound was bandaged. Wound care instructions were reviewed. The patient tol erated the procedure well. Pathology results will be mailed to the patient. 2. Actinic keratosis, left upper cutaneous lip. This lesion was treated wi th liquid nitrogen cryotherapy x2 cycles. Postprocedural care and expectations were discussed with the patient. She tolerated the procedure well. Additionall y, I have advised the patient if she still is having some textural changes at fo ur weeks. I have given her samples of Solaraze to use to the area twice daily f or a period of 60 days. In the event, it does not clear with it, freeze today. 3. Lentigo on the sun exposed areas of the arms and legs. The patient was reassured regarding the benign nature of these lesions. These lesions do, howev er, indicate diffuse sun damage. We discussed the importance of wearing a broad -spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the s un. 5. Seborrheic keratosis. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. 6. History of non-melanoma skin cancer. We discussed monthly skin checks, looking for any new or changing pigmented lesions. We also asked the patient to look for an irregular border, asymmetry, change in color or increase in diamete r of any pigmented lesion. Today I reviewed sun protection guidelines. I discu ssed ABCD s and the use of sunscreen. I also recommended monthly self skin exam. T he patient understands we should be notified for any changing lesions, new, or c oncerning lesions. I also discussed the use of wearing a hat and avoiding outdoo r sun exposure at the peak sun hours. Follow up pending pathology results, othe rwise follow up will be in six months for upper body skin exam given the past hi story of non-melanoma skin cancer. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\patricia jill samples consolidated\06-14-12\061412_pjl.doc 7/28/2012 1:02: 26 PM 78848 The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Ms. Shaffer presents to the office today for a cosmetic consult on the lower face and neck region. Current medications, the patient states will fa x the list to us. She states she is allergic to sulfa. The patient has never b een in a tanning bed and is an occasional drinker and nonsmoker. OBJECTIVE: On exam, she is a well-developed, well-nourished Caucasian female, i n no apparent distress. I did examine today the face and neck region, she does have some marked laxity of the lower face and neck region with some static and d ynamic rhytides present in the glabellar region as well as the nasolabial folds, marionette lines, and neck consistent with age related changes. The patient do es not wish to do plastic surgery. I have advised her that short of plastic sur gery _____ dramatic results will be laser surgery. I have recommended cosmetic

consult with Dr. Lawrence Chang for possible IPL or carbon dioxide laser resurfa cing for the lower face and neck. He will be setting this up on Monday and ____ _. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Catherine presents today for total skin exam. The patient has a hi story of nonmelanoma skin cancer treated via Mohs surgery on the nose and nasola bial fold. The revision by Dr. _____. She states she does have a couple of are as of concern on the right brow and the left cheek. The patient has a history o f actinic keratosis of the face. The nonmelanoma skin cancer of the nose and up per lip was diagnosed as basal cell carcinoma. She denies any history of diabet es or infectious disease. OBJECTIVE: The patient is a well-developed, well-nourished Caucasian female, in no acute distress. I did examine today the face, scalp, ears, chest, neck, bac k, abdomen, arms, legs, hands, and feet today. She does have some well-healed s cars on the nasal tip and _____ basal cell carcinoma and no signs of recurrence were noted today. On the lateral aspect of the right brow, she does have two il l-defined waxy erythematous plaques consistent with actinic keratosis and one al so on the left upper lip and one on the left zygoma region as well also consiste nt with actinic keratosis. On the bottom of the right foot, she has a symmetric ally evenly pigmented well marginated brown nevus that measures 9 mm x 7 mm. On the bottom of the left foot, she has a brown evenly pigmented well marginated n evus measuring 6x4 mm. These have remained stable since last visit. She also h as scattered lentigines on the sun exposed areas of the upper body, most notably in the dorsum of the forearms and the back of shoulders consistent with symmetr ical cherry red papules consistent with cherry hemangioma. There are also some fleshy-pedunculated growths consistent with skin tags in the axillary vaults bil aterally. 1. Actinic keratoses four were treated today, two on the right lateral aspe ct of the eyebrow, one on the left upper lip, and one on the left cheek with liq uid nitrogen cryotherapy x2 cycles. Postprocedural care and expectations were d iscussed with the patient and she tolerated the procedure well. 2. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 4. Benign nevi plantar surface of the feet bilaterally have remained stable . No change since last year skin exam. Today I reviewed sun protection guideli nes. I discussed ABCD s and the use of sunscreen. I also recommended monthly self skin exam. The patient understands we should be notified for any changing lesion s, new, or concerning lesions. I also discussed the use of wearing a hat and avo iding outdoor sun exposure at the peak sun hours. 5. History of basal cell carcinoma. We discussed monthly skin checks, look ing for any new or changing pigmented lesions. We also asked the patient to loo k for an irregular border, asymmetry, change in color or increase in diameter of any pigmented lesion. Followup will be in one year for her next total skin exa m unless of course she needs sooner. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Patricia presents to the office today for rosacea as well some mole s of concern that she would like addressed. The patient has used metronidazole cream perhaps two times in the past. She states she is not on the cream and/or pill _____ and is very worried to use the cream on a daily basis for her papular pustular rosacea. She gives a personal and family history of papular pustular rosacea. At times, she has had some infected pustules to which her doctor had g iven her mupirocin 2% cream in the hopes of saving off secondary infection. She is allergic to sulfa, codeine, Polysporin, and dyes. She is a nondrinker and n onsmoker. She has never used a tanning bed. She denies any personal or family history of skin cancer, but does admit to blistering sunburns as a child. ASSESSMENT/PLAN: Papular pustular rosacea. I have been advised the patient, I

would like to give a two-month trial of both topical and low-dose doxycycline th erapy to the patient to see if we can call the inflammatory response and then de termine if there are precancerous that needed to be treated at that time. I hav e written her for the MetroGel 0.75% cream, which I would like foe her to apply q.a.m. over the next two months and also I have given her doxycycline 20 mg caps to take one cap p.o. b.i.d. over the next 60 days and then followup for her ros acea and to evaluate any potential precancerous lesions. I have advised follow up with Dr. Alan Rolfe on Friday for dermatoscope review of a couple the areas o f concern, namely one inflammatory papule on the submental region central chin a nd other on the right nasal side wall directly under the eyeglass pad. She will follow up for this in approximately six to eight weeks with Dr. Alan Rolfe on t he Friday. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Dennis presents to the office today for his yearly skin exam. The patient states no current medications. He is not allergic to any medications th at he knows of. He denies any personal history of skin cancer. His family hist ory of skin cancer is unknown. He admits to blistering and sunburns as a child and denies tanning bed use. He is an occasional drinker and nonsmoker. 1. Lentigo. Courtesy freeze was done to approximately 10 of the lentigines on the dorsum of the hands bilaterally, five on the left hand and five on the right hand with liquid nitrogen cryotherapy x2 cycles. Postprocedural care and expec tations were discussed with the patient. He tolerated the procedure well. 2. Seborrheic keratosis. The patient was informed of the benign nature of thes e lesions and no treatment is necessary at this time. 3. Hemangioma. The benign nature of the lesions was discussed and no treatment is necessary at this time. We discussed monthly skin checks, looking for any n ew or changing pigmented lesions. We also asked the patient to look for an irre gular border, asymmetry, change in color or increase in diameter of any pigmente d lesion. Today I reviewed sun protection guidelines. I discussed ABCD s and the use of sunscreen. I also recommended monthly self skin exam. The patient underst ands we should be notified for any changing lesions, new, or concerning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours. The importance of daily sun protection was discussed. The patient was given an informational brochure on skin cancer and a starter sample of a complete sun block. Followup will be in approximately one year for his nex t total skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ASSESSMENT/PLAN: Cosmetic salicylic acid peel done in office today, series two out of package of four. Skin was cleansed in a sterile alcohol swab was area to be treated. A 30% salicylic acid solution was then applied to the face with st erile gauze pad and leftover three minutes. It was then neutralized with bacter iostatic normal saline and then protective SPF 30 calming moisturizer was then a pplied. The patient tolerated the procedure well. Aftercare was discussed with the patient and all concerns were addressed and questions answered in the offic e today. Followup will be in four weeks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Logan presents to the office today for a refill for medication of h is acne. He states he is doing benzoyl peroxide wash with Tazorac 0.1% cream a small pea-sized amount to the face and doing quite well for his mild acne vulgar is. He states he also is in today with his mother to have some moles checked on the upper body. The patient denies any personal history of skin cancer. He do es have a paternal grandmother that has had something that may have bothered her face. His mother does admit to the grandmother being a sun worshiper, they are unsure which type of skin cancer whether melanoma or nonmelanoma, but states gr andmother is still alive. He states he is not allergic to any medication that h e knows off. He has never been in a tanning bed. He is a nondrinker and nonsmo ker.

1. Acne vulgaris post inflammatory changes. I have refilled the patient s pr escription of the Tazorac 0.1% cream as he states this has maintained excellent control of his acne on the face and chest, we will have him continue on with thi s in his morning acne wash over the next year. 2. Benign nevi on the face, neck, and trunk. He does have some variations and pigment in border on almost half of his nevi distributed about the neck, bac k, and chest. I have advised a six-month upper body skin exam to be conducted w ith dermatologist Alan E. Rolfe under dermatoscopic review, which he confirm all nevi are in deep benign. Of note, the patient does state no symptoms associate d with any of the lesions, no spontaneous bleeding, no changes, no itching, no c rusting etc. Followup in six months for a dermatoscope exam with Dr. Alan Rolfe for his nevi. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Aliz presents to the office today for beginning a month one of her Accutane therapy. Based on labs have come in and HCG serum less than 1, which i s negative, AST at 11, ALT at 7, triglycerides of 151, and this is too over norm al. The patient states that when she recalls back that she does think she was f asting prior to obtaining labs. She has currently been using Tazorac topically prior to initiating Accutane therapy. These labs are drawn from LabCorp on date of draw 06/11/2012. ASSESSMENT/PLAN: Acne vulgaris with postinflammatory changes and scarring. The patient is to start first-month of Accutane therapy today. The patient s labs ha ve been entered in today s heart chart and she is cleared to be confirmed today in the iPLEDGE system and this will be done by dermatology assistant, Nick Lee. T he patient has been informed she is to answer the small battery of questions onl ine and then The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ASSESSMENT/PLAN: Acne vulgaris of the face and acneiform folliculitis of the ba ck with postinflammatory changes. The patient is very pleased with the clearanc e she has gotten from the doxycycline therapy with regards to the face and back. She will continue on with doxycycline 100 mg capsule one cap p.o. q.d. and we are going to taper down and discussed discontinuation of doxycycline entirely in three months. For now, she will continue to use the Ziana to the face and back , pea-sized amount to face, pea-sized amount or two pea- sized amounts to back q .h.s. and she can continue on the CeraVe a.m. and p.m.. The patient moisturizer s to help on sun irritation and dryness. Followup will be in approximately ther e months. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\patricia jill samples consolidated\06-18-12\061812_pjl.doc 7/28/2012 1:02: 29 PM 184320 SUBJECTIVE: Mr. Frank presents to the office today for outbreak he has had over the last week after he reported getting into some weeds. He stated he develope d rash along the left inner arm and the right outer leg, which he states also go tten on to his neck and face. He believes it is allergic contact in nature. He was seen by Patient First and given a six-day course of 10 mg of prednisone dai ly. He was also given a Celestone shot. His current daily medications include simvastatin and HCTZ combo, which he states he has been on both for years. The patient also states he is prediabetic, but not on any oral diabetic medications at this time. ASSESSMENT/PLAN: Dermatitis, not otherwise specified, likely ACD continuing to smolder despite six-day prednisone and prednisone shot given last week. The pat ient has been using fluocinolone. I am going to increase the strength of that t o clobetasol 0.05%. He is going to apply this twice daily to the affected areas of the neck and below. On the face, he will use desonide 0.05% cream. I have written him for a 60 g tube of clobetasol with one refill and a 30 g tube of des

onide with one refill. I have advised the patient to discontinue once the flare s have stopped. Side effects of the topical steroids were discussed with the pa tient, he understands. I have also given him Atarax 25 mg tablets take one tabl et p.o. q.h.s. p.r.n. itch, #30 with no refills. We will have Mr. Frank followu p to the office if no improvement noted over the next two weeks. Otherwise, fol low up is open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Laura presents to the office today for abscesses and skin infection s under her arms, the tops of her breasts and also some which appear, she states , on her legs. She states that there are no abscesses that are active currently . She has never been told what this condition is and states she has never used anything topically on it. However, she has been given some antibiotic therapy i n the past orally she is unsure of which type and she states she has used it for possibly a month at most. The patient is not currently on any medications. Sh e is currently breast-feeding her eight-week-old daughter. She is not allergic to any medications that she knows of. She is nondrinker and nonsmoker. She has been on a tanning bed approximately 100 times in her life. OBJECTIVE: Physical examination reveals a well-developed, well-nourished Caucas ian female, in no apparent distress. I did examine the axillary vaults bilatera lly today as well as the top of the chest. She does have some scarring and hype rpigmentation from older healed up boils, this looks to be consistent with hidra denitis suppurativa based on the patient s history and examination of the axillary vaults bilaterally. ASSESSMENT/PLAN: Hidradenitis suppurativa. Because the patient is breast-feedi ng, I have recommended only a multivitamin with zinc supplement as well. She ma y also do benzoyl peroxide topically to the affected areas. I have written her for Brevoxyl 8% wash and she may also after washing put a thin film of clindamyc in 1% lotion to the area. I have written her for a large bottle with p.r.n. ref ills as well. I have advised the patient when she discontinues nursing to retur n to the office and at that point we will be initiate 90 day trial of doxycyclin e therapy dosed at one 100 mg capsule p.o. b.i.d. Again, I would like to do a 9 0-day trial and see how she responds to the oral antibiotic therapy. I have giv en the patient website to familydoctor.org as well as the name of her condition so that she may do some further research. At this point, follow up is open-ende d dependant on her discontinuation of her nursing. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Shirley presents to the office today for total skin exam. The pati ent denies any personal or family history of skin cancer. She does, however, ad mit to blistering sunburns as a child as well as tanning bed use more than 20 ti mes in her life. 1. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 4. Seborrheic keratosis. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. 5. Sun damage. INSERT SUN DAMAGE MACRO ________. She does have a well-dem arcated annular area of erythema on the nasal tip, which she states becomes angr y every summer, especially when she gets sun exposer. The patient was seen by b oth myself and Dr. David Pariser regarding this erythema on the nasal tip. Dr. David has discussed with the patient that this is secondary to sun damage, altho ugh it does not look precancerous or cancerous in nature to him at today s visit. I have advised the patient to use a heavy sunscreen and a physical blocker in t hat area. The importance of daily sun protection was discussed. The patient was given an informational brochure on skin cancer and a starter sample of a comple te sun block. We discussed monthly skin checks, looking for any new or changing pigmented lesions. We also asked the patient to look for an irregular border, asymmetry, change in color or increase in diameter of any pigmented lesion. Tod

ay I reviewed sun protection guidelines. I discussed ABCD s and the use of sunscre en. I also recommended monthly self skin exam. The patient understands we should be notified for any changing lesions, new, or concerning lesions. I also discus sed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun h ours. Follow up will be in one year for her next total skin exam unless of cour se she needs our services sooner. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Shane presents today with his mother for followup of bacterial cult ure results taken from one of the acne pustules on the back at last date of visi t 06/11/2012. Bacterial cultures have been returned showing no organisms. No a ny white blood cells seen on Gram stain with a few epithelial cells noted. Fina l report shows few skin flora. No predominating beta strep, Staph aureus, enter ococcus, Gram negative rods, anaerobes, or yeast isolated. Of note, the patient s mother has brought in some doxycycline that Shane had used where he was given a prescription from his primary care doctor to take one 100 mg tablet twice daily . He states he had used them for a few weeks and then stopped using them as he felt they were not working. With regards to the BenzEFoam and Clindagel, the pa tient has been using that and states that he has noticed a slight improvement ov er the last week. OBJECTIVE: On examination, he is a well-developed and well-nourished Caucasian male, who accompanied by his mother in office today. The patient is alert and o riented and appears in no acute distress. Face is clear. It is spared from any acneiform eruptions. However, on the back, he does have some three inflammator y pustules as well as some inflammatory papules consistent with acne vulgaris/ac neiform folliculitis of the trunk. He does also have some postinflammatory hype rpigmentation from older resolving lesions on the trunk. ASSESSMENT/PLAN: Acne vulgaris/acneiform folliculitis of the trunk with postinf lammatory changes from older resolving lesions. I would like for the patient to continue with the doxycycline therapy taken as follows, one 100 mg tablet p.o. b.i.d. The patient states he has 90-day supply. I have advised him to call in should he need refills prior to follow up. He will continue on the topical Benz EFoam short-acting 9.8% ultra to be used before each shower. Also, he can conti nue on with a thin-film of Clindagel to the chest and back. He has also been gi ven Epiduo to use by his primary care provider, which he was using in concordanc e with the doxycycline. I have advised the patient to continue on with this at night as tolerated. We will follow up in approximately three months. Side effe cts of the doxycycline were revisited with the patient and his mother today in t he office. They voiced understanding. Follow up in three months. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Christine presents to the office today for total skin exam. The pa tient is employee here at Pariser. She denies any blistering sunburn as a child , but does admit to tanning use in the past. She had a lesion on the right uppe r shoulder removed at last date of service 06/20/2011, which was consistent with a benign lichenoid keratosis. She has no concerns at today s office visit. 1. Benign nevi. All nevi are well marginated, homogenously pigmented, symm etrical, benign appearing moles. We reviewed ABCDs of melanoma. The patient wi ll monitor moles for any change or growth. The patient understands if any of th ese lesions begin to change, they are to return to clinic for re-evaluation. 2. Lentigo. The patient was reassured that these are benign lesions. They do however, indicate diffuse sun damage. We discussed the importance of wearin g a broad- spectrum sunscreen with an SPF of 30 or greater whenever she is expos ed to the sun. A handout of recommended broad-spectrum sunscreens was given to the patient as well as numerous broad-spectrum sunscreen samples. 4. Seborrheic keratosis. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. 5. Dermatofibroma. The patient was reassured of the benign nature of this condition--no treatment is necessary. We discussed monthly skin checks, looking for any new or changing pigmented lesions. We also asked the patient to look fo

r an irregular border, asymmetry, change in color or increase in diameter of any pigmented lesion. Today I reviewed sun protection guidelines. I discusse d ABCD's and the use of sunscreen. I also recommended monthly self skin exam. T he patient understands we should be notified for any changing lesions, new, or c oncerning lesions. I also discussed the use of wearing a hat and avoiding outdoo r sun exposure at the peak sun hours. Follow up will be in approximately one ye ar for next total skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Heather presents to the office today for a tender spot on the back, which she states this has been painful in nature over the last few months. The patient gives no personal or family history of skin problems or skin cancer. S he denies tanning bed use, but does give a history of excessive sun exposure as a child through the teenage years, also as a young adult, as well as blistering sunburns as a child numerous in nature. She is allergic to erythromycin and Dif lucan. She is currently taking Campral, Neurontin, and Zoloft. She does drink. She does also smoke. 1. Neoplasm uncertain rule out ISK versus atypical nevus versus dysplastic nevu s versus irritated nevus. After obtaining a written consent, the patient was pr epped with alcohol. Buffered Lidocaine with epinephrine 1% was administered for local anesthesia. The lesion was biopsied via a shave technique using a DermaB lade. Drysol was used for hemostasis. Polysporin ointment was applied to the w ound and covered with a bandage. Wound care was reviewed. The patient tolerate d the procedure well. Pathology results will be mailed to the patient. 2. Benign nevi of the trunk. All nevi are well marginated, homogenously pigmen ted, symmetrical, benign appearing moles. We reviewed ABCDs of melanoma. The p atient will monitor moles for any change or growth. The patient understands if any of these lesions begin to change, they are to return to clinic for re-evalua tion. 3. Lentigo. The patient was reassured that these are benign lesions. They do however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF of 30 or greater whenever she is exposed t o the sun. Follow up will be pending pathology results. The patient requests t o have a total skin exam done in August 2012. At that time, we will revisit the acne scarring on the face. I have advised her to initiate care for her skin wi th a benzoyl peroxide wash use daily. If she does not notice improvement at fol lowup visit in August, we will discuss prescription strength topicals at that ti me. Other than the scarring, no new inflammatory lesions are seen today. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Latashoa presents today for acne on the face, chest, and shoulders. She is not currently taking any medications nor is she allergic to any medicat ions. She states adult onset acne and she has not had a history of this in the past. The patient is a nondrinker and nonsmoker. She has never used a tanning bed. ASSESSMENT/PLAN: Acne vulgaris with postinflammatory hyperpigmentation. I have spent approximately 15 minutes in office today advising and personalizing Retin -A acne regimen to the patient to include the following: CeraVe Foaming Face Wa sh to be used both daily and nightly as a gentle face wash. She is to apply thi n film to the face of the Benzamycin gel q.a.m. At night, she may wish to use t he CeraVe AM cream as it does have sunscreen in it to help with the discoloratio n and it is also noncomedogenic. At night, she is to wash the CeraVe Foaming Fa ce Wash and apply a pea-sized amount of Differin gel to the face spreading into a thin film starting every other night titrating up to nightly as tolerated. Si de effects of all medications were discussed with the patient. She voiced under standing. I have also advised her that she may experience some dryness and irri tation from the retinoid topical therapy. She may _____ with CeraVe PM used dir ectly after putting on the Differin gel. Expectations of the course of acne and acne treatment were discussed with the patient in office today. I have advised her to expect a potential flare-up over three to four weeks time and stressed th

at compliance is key over the next eight weeks. Follow up in two months time. S amples of the CeraVe products as well as the Differin gel are given to the patie nt in office today as well as coupons. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Khadaeja presents to the office today for outbreak on left part of her body. She has itchy outbreak present on the arms, neck, legs, and stomach. The patient has a history of nickel allergy with autoeczematization in the past . 1. Atopic dermatitis with a likely allergic contact dermatitis/id reaction to nickel. I have discussed with the patient that no matter what steroid we use and strength, if she continues to come in contact with the nickel, she will con tinue to have these problems. Both patient and mother stated understanding. I am going to give her a large triamcinolone 0.1% ointment and I have advised her to use this only on the neck and below avoiding delicate skin areas. For itch a t night, she may opt to take Atarax, so I have written her for 10 mg tablets, sh e may take one to two p.o. q.h.s. p.r.n. itch. The patient weighs approximately 90 pounds. 2. Acne vulgaris, postinflammatory hyperpigmentation, primarily comedonal i n nature. I have spent approximately 15 minutes in the office today devising a personalized acne regimen for the patient to include CeraVe Foaming Face Wash to use daily and nightly. She is then to apply a small pea-sized amount of Differ in 0.3% gel to the face at night. The course and expectations of retinoid acne therapy were discussed with the patient to include expecting a flare anywhere fr om three to four weeks into therapy. I have stressed the importance of complian ce with both the patient and her mother of adhering to the regimen over the next eight weeks. Follow up will be in two months time. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Serethia presents to the office today noting marked improvement of her hand dermatitis with the use of the clobetasol used once or twice daily p.r. n. flares and the Neosalus barrier cream. The patient states that she is good o n refills today. OBJECTIVE: On exam, she is alert and oriented, well-appearing African-American female, in no acute distress. On examination of the hands today, they are free and clear of any spongiotic appearing patches. She just does have some generali zed xerosis consistent with the dyshidrotic component of her atopic dermatitis. It looks to be under good control with the use of the clobetasol and the Neosal us cream. We will continue on with the current treatment regimen. The patient may call in for refills as needed. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Christine presents to the office today for total skin exam as well as refills on medications for her papulopustular and erythrotelangiectatic rosac ea. She is currently using MetroGel q.a.m., Finacea q.h.s., and Oracea q.d. and states that this does work well for her. The patient does admit to a number of triggers to include coffee, _____, tomatoes, and spicy foods. She does also ju st one area of concern today on the left breast, which she states has risen over the last few months. The patient denies any personal or family history of skin cancer. She does admit to sunburns as a child and has never used the tanning b ed. 1. Neoplasm uncertain of left breast at 7 o clock, rule out ISK versus SCC. After obtaining a written consent, the patient was prepped with alcohol. Buffer ed Lidocaine with epinephrine 1% was administered for local anesthesia. The les ion was biopsied via a shave technique using a DermaBlade. Drysol was used for hemostasis. Polysporin ointment was applied to the wound and covered with a ban dage. Wound care was reviewed. The patient tolerated the procedure well. Path ology results will be mailed to the patient. 2. Lentigines. The patient was reassured regarding the benign nature of th ese lesions. These lesions do, however, indicate diffuse sun damage. We discus

sed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or grea ter whenever they are exposed to the sun. 4. Rosacea, both papular and erythrotelangiectatic in nature. The patient will continue on with MetroGel use q.a.m., Finacea use q.h.s., and doxycycline o r Oracea therapy 40 mg one tablet q.d. Follow up will be pending the results of pathology from the left breast, otherwise her yearly skin exam will be next Jun e of 2013. Prescriptions and co-pay coupons were given for all three products t oday in office. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Cameron presents to the office today accompanied by her father for some pimples, which have bothered her in appearance over the last year. She doe s have a sister with acne and a maternal grandfather with psoriasis. She has be en using Ulta over-the-counter washes as well as had extraction done at numerous places of beauty. She gives a personal medical history of allergies and hives. She is a nondrinker and nonsmoker. The patient states that she is not having any scalp involvement. The scalp does not itch nor does her acne itch on the fa ce. 1. Acne vulgaris with some postinflammatory changes, primarily comedonal in nature. I have given the patient personalized acne regimen in the office today to include CeraVe Foaming Face wash to use daily and nightly. I have then pres cribed her BenzaClin, which I would like for her to apply to the face and spread into a thin film in the a.m. I have given her some CeraVe AM in the incidence that this might be too drying for her. I have given her some CeraVe AM, which s he may use with moisturizer and a sunscreen as this will help offset the dryness caused by the benzyl peroxide products during the day. At night, I have advise d a small amount of Differin gel to be applied to the skin starting on Monday an d Friday, or Monday, Wednesday, and Friday, titrating up to nightly use only as tolerated. She may distribute a pea-sized amount of the face and spread into a thin film using the CeraVe PM moisturizer afterwards to help offset any dryness and irritation that the topical retinoid may cause. The course and expectations of acne therapy were discussed with the patient to include expecting a breakout of approximately in 3-4 weeks to include expecting a flare-up rather approximat ely 3-4 weeks into therapy. I have stressed compliance over the next eight week s with these topicals and we will meet back up in two months to reassess. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Acne vulgaris with postinflammatory changes. Approximately 15 minutes w ere spent in the office devising a personalized acne regimen for the patient to include the following. CeraVe Foaming Face Wash to be used both daily and night ly, also in the morning she is to apply a thin film of BenzaClin gel to the face and spread into a thin film before applying makeup. If this is too dry and she may opt to use the noncomedogenic CeraVe and moisturizer. I have advised her t his sunscreen will also help prevent further discoloration of the older acneifor m papules. At night, she is to use the CeraVe Foaming Face Wash and then apply a pea-sized amount of the Differin 0.3% gel to the face spreading into a thin fi lm. She may wish to use the CeraVe PM lotion or some other nighttime moisturize r to help offset the redness and irritation, the topical retinoid may indeed cau se. All side effects of the medications which were written today were discussed in the office with the patient. She voiced understanding. The patient is not currently on any daily medication nor is she allergic to any medications. The c ourse of acne treatment was discussed with the patient. She has been instructed to expect the flare-up in approximately 3-4 weeks potentially. I have stressed compliance over the next eight weeks to see if topical therapy will indeed be b eneficial to her. 2. Nevi. All nevi are well marginated, homogenously pigmented, symmetrical , benign appearing moles. We reviewed ABCDs of melanoma. The patient will moni tor moles for any change or growth. The patient understands if any of these les ions begin to change, they are to return to clinic for re-evaluation. Follow up in two months.

The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Christina presents to the office today for facial breakouts that sh e has had over the last six months. It bothers her in appearance. The patient gives no other history of skin problems or any family history of skin problems. She is not allergic to any medications that she knows of nor is she taking any daily medications. She is a nondrinker. She does occasionally smoke tobacco. The patient denies any pertinent past medical history or past surgical history. OBJECTIVE: Physical examination reveals a well-developed, well-nourished Africa n American female, in no apparent distress. I did examine today the scalp, face , neck, trunk, and bilateral upper extremities. The trunk is spared of any acne iform type lesions. On the face, she does have some open and closed comedones m ost notably on the forehead, nose, and chin region. She does have a few scatter ed inflammatory papules on the cheeks bilaterally with some postinflammatory cha nges from older resolving lesions. The patient also points to hyperpigmented li chenified thickened patch on her left elbow, which looks to be consistent with l ittle patchy xerosis. She gives no past history of eczema and states that it on ly itches occasionally. She has only had it over the last four weeks. ASSESSMENT/PLAN: Acne vulgaris postinflammatory changes. The patient and I sat down and together developed a personalized acne regimen. Approximately 15 minu tes were spent devising this regimen to include the following: CeraVe foaming c leanser to use both daily and nightly, also in the morning, she will apply thin film of Benzamycin to the face. After washing her face at night, she will apply a pea-sized amount of Differin 0.3% gel to the face starting out with every oth er night use titrating up to nightly, use only if tolerated. Samples and coupon s were given to the patient in office today of the CeraVe as well as the Differi n. She was also given CeraVe AM and PM facial moisturizers to help offset the d ryness associated with the Benzamycin and the topical retinoid products. Side e ffects were reviewed with the patient in the office today, she voiced understand ing. For the xerosis on her left elbow, I have given the patient some steroid s amples of Trianex to use twice daily over the next week, this should clear this up nicely. If there is any need for followup with regards to the dermatitis on the left arm, she may follow up immediately; otherwise, follow up will be in two months for acne followup. I have advised the patient that she may expect a bre akout 3-4 weeks into her topical therapy regimen. I have advised her that this is normal and to continue on adhering to the regimen for the full eight weeks. Follow up in two months. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Ms. Thompson presents to the office today for a followup of a coupl e of areas of concern. She did have two biopsies done by Dr. Cyndi Torosky back on last date of service, 05/08/2012, showing upper chest consistent with benign lichenoid keratosis and left medial canthus consistent with precancerous actini c keratosis. She is also in today for initiation of Accutane therapy as she has had both minocycline and doxycycline therapies over the last year and is anxiou s to start the Accutane. The patient has a history of a complete hysterectomy a t age 29 done back in 1992. She is able to begin Accutane as a female of non-ch ildbearing potential. The patient does have a history of malignant melanoma x2, one on the right leg in May of 2009 and one on the right posterior thigh in Apr il of 2010. Both were stage-I. She had used Accutane approximately seven years ago, but it was discontinued due to potential side effects. Right now, she is currently using Ziana. Past medical history, medications, and social history we re reviewed with change in the following medications: Baclofen, Mucinex, Zetia, and Nasonex. She is no longer taking Allegra, she is taking Xyzal 10 mg. She is no longer taking ____. She is taking Ambien, but it is now Ambien CR. She i s still taking Restasis. She is on Mirapex and she also is continuing on with N exium and Amitiza 24 mcg. She has four more days left of Lamisil 250 mg for her onychomycosis and she is taking estradiol cream vaginally and 1 mg tablet each day for menopausal symptoms. She has no known drug allergies. OBJECTIVE: On exam, she is well-developed, well-nourished alert female, in no a

cute distress. I did examine the areas of concern today. The patient points to the area on the chest, which she thought she was told was a precancer. I have advised the patient this is a benign lichenoid keratosis and have offered to tre at it in office today via liquid nitrogen cryotherapy. She also points to a cou ple of areas of concern over the lateral aspect of the right brow. These are le ntiginous in nature. I have advised the patient this is secondary to cumulative sun exposure and they are benign as well. On examination and palpation of the right medial canthus today, no textural changes are noted. This appears to be s mooth in nature and looks like the removal of the actinic keratosis on biopsy wa s indeed curative. Robert J. Pariser has examined the patient with me in office today examining all areas mentioned above and states that none of them at this time need any type of treatment, nothing precancerous are cancerous is noted at today s visit. The patient does have on examination of the face some ice pick lik e scarring on the bilateral cheeks region consistent with acne vulgaris with a f ew inflammatory papules noted on the chin and jawline consistent with acne vulga ris. 1. Irritated seborrheic or lichenoid keratosis on the central upper chest. The patient has decided to have this removed as it is irritating to her, theref ore I have frozen it with liquid nitrogen cryotherapy x3 cycles. Postprocedural care and expectations were discussed with the patient. She tolerated the proce dure well. 2. History of malignant melanoma x2. We discussed monthly skin checks, loo king for any new or changing pigmented lesions. We also asked the patient to lo ok for an irregular border, asymmetry, change in color or increase in diameter o f any pigmented lesion. Today I reviewed sun protection guidelines. I discusse d ABCD s and the use of sunscreen. I also recommended monthly self skin exam. Th e patient understands we should be notified for any changing lesions, new, or co ncerning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours. 3. Acne vulgaris with some textural scarring on the face from older acne wi th treatment failure noted to minocycline and doxycycline. Accutane counseling was done in office today by dermatology assistant Dr. Madison O'Brien. The pati ent is going to begin the iPLEDGE program. he patient understands the risks and benefits of being on Accutane, especially those risks to an unborn fetus leadin g to severe birth defects. She must commit to two iPLEDGE Program acceptable for ms of birth control and start using both forms of birth control together for at least one month before starting Accutane, throughout the course of treatment and for one month after completing treatment. The patient understands that she must have two negative pregnancy tests, the first to get started in the iPLEDGE prog ram, and the second before she actually starts Accutane. These tests must be at least 31 days apart. The patient is exempt from the birth control requirements of the iPLEDGE Program if; (1) She has stopped having periods for 12 months in a row and her physician says she is in menopause, (2) She has had both ovaries or uterus removed, (3) H er ovaries are not viable and she cannot get pregnant, this must be confirmed by her doctor, or (4) The patient commits to not having sexual contact with a male at any time for at least one month before, during, and one month after her last dose. 4. Lentigo, right lateral brow. At the patient s request, these were frozen with liquid nitrogen cryotherapy x2 cycles in a light freeze fashion. Follow up will be in four weeks for followup and starting month-2 of Accutane therapy. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Harlem presents to the office today for area of concern on the face . The mother has noted some discoloration on the area over the last couple of w eeks. The patient gives no personal history of skin problems or any family hist ory of skin problems as related to her mother. She also has what the patient s mo ther believes to be some bug bites which she states are still itchy to the patie nt. She does have a history of seasonal allergies and is currently on Children s Zyrtec and/or Claritin over-the-counter for non-drowsy allergy relief during the

day. ALLERGIES: The patient is not allergic to any medications that she knows of. OBJECTIVE: Physical examination reveals a well-developed, well-nourished young African-American female, in no apparent distress. I did examine today the scalp , face, neck, trunk, and bilateral upper and lower extremities. On examination of the scalp today, this remained clear of any fine plaquing or xerosis. On the face, she does look to have a couple of hyperpigmented patches on the glabellar region and the right malar cheek region, which looked to be consistent with pos sible tinea pedis and is asymmetrical in nature and no involvement is present on the left side of the face. With regards to the bug bites, she has approximatel y three hyperpigmented papules on the left leg, three on the right leg, and one on each eye, which looks to be consistent with an insect bite reaction. We will quote this as dermatitis, not otherwise specified, likely insect bite reaction at today s visit. With regards to the nails, the patient s mother would like her na ils evaluated. She states she did take her to get her nails done and they did f ile them horizontally, which the patient s mother noticed when she removed the pol ish that she had gotten some textural changes on the nail. On examination today , it does look like there is no yellow discoloration present or hyperkeratotic b uildup, however, there is some evident trauma to the nailbed in the form of poss ible emery board. I have notified the patient s mother that the nailbed will need to grow out to determine how the nailbed is going to resolve after this trauma period, but I have advised no more trips to the nail salon until the bed has gro wn out and we can determine if there is any discoloration or secondary problems. If so, we will do a fungal culture later on down the line. At this time, I re commended she do her daughter s nails at home. With regards to the dermatitis, no t otherwise specified, of the glabellar and right cheek region, the patient was seen by both myself and Dr. Robert J. Pariser in our office today. He does beli eve that this is likely tinea versicolor in nature. We are going to treat with ketoconazole 2% cream to apply to the affected areas of the face twice daily for up to one week past clearing. I have advised the patient to give it three or f our weeks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Ramon presents today for followup of biopsy on the left lower back. Pathology results, which have come back as likely confluent and reticulated pa pillomatosis of Gougerot-Carteaud. The patient presents for suture removal. Pa tient has no complaints about the surgical site, and the wound has healed withou t any complication. The wound was cleansed and sutures were removed. The patie nt was instructed to call me if there is any concern about the surgical site in the future. This was done by dermatology assistant Nickel Martin in office toda y. The patient denies any fevers, sweats, or chills from stated biopsy or any a bnormal oozing, bleeding, crusting, or drainage from the wound. ASSESSMENT AND PLAN: I have consulted with Dr. Robert J. Pariser regarding this patient s pathology report. I am going to start him on a trial of minocycline 10 0 mg tablets to take one tablet by mouth twice daily, I have written him for 60 tablets with two refills. We will see if indeed two or three-month course of or al minocycline may be enough to suppress this into remission. I would like to s ee the patient back in approximately four weeks to see what his initial response is. I have discussed the side effects of minocycline therapy with the patient in office today to include photosensitivity, headache and stomach upset. If he experiences any of these, he is to discontinue the medication and call the offic e at once. The patient voiced understanding. Follow up will be in four weeks. I have given the patient a website to go to and to further research this condit ion as it is somewhat rare in nature. We will see him in four weeks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Ms. Simone presents today for a patch test placement. She states s he had seen Dr. Molly on last date of service 06/06/2012 where she had suspected it may be a reaction to her new Parkinson s medication. Dr. Molly had suggested patch testing to rule out anything contact; however, she wanted Jane to be off h

er oral steroids for a period of one week. The patient is in today having disco ntinued the steroids approximately one week ago. She is in today for a patch te st placement. MEDICATIONS: The patient s current medication and allergy list has been copied to day and scanned into the Jane Simone patient s correspondence file. Of note, she is starting insulin this week, hence possibly being discontinued of the glipizid e, Glucophage, and Januvia medications. She is currently on Precose, isosorbide , metoprolol, clonazepam, levetiracetam (is also known as Keppra), and she has d iscontinued that for the past 10 days. This was an anti-seizure medication. Sh e is still on aspirin 325 mg and furosemide 40 mg daily. ASSESSMENT/PLAN: Dermatitis, not otherwise specified, suspected hypersensitivit y reaction. Patch test placement was done today in office as the patient has be en steroid-free for over one week. This was placed in the office by dermatology assistant Nichol Martin. I have advised the patient follow up would be in appr oximately 48 hours at which time she will have an acute reading and then at 96 h ours on Friday, she will be following up to have a delayed reading and discuss a nd tailor good treatment plan at that time. I have given her informational pamp hlet for the true test allergy test and answered all questions and concerns she had with regards to the test in office today. Follow up in 48 hours. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. ASSESSMENT/PLAN: Acne vulgaris postinflammatory changes on the face. I have ad vised that the patient to do over-the-counter benzoyl peroxide wash to the area and I have given her some clindamycin lotion, which she may apply a thin film to the face topically each morning. With regards to the hidradenitis suppurativa, she also may use the benzoyl peroxide wash to wash the armpits q shower. She i s also able to apply a thin film of the clindamycin 1% lotion to the axillary va ults in the morning. I have advised her that since she showers at night she may use the benzoyl peroxide wash at night and then after she has gotten out of the shower and dried off she may apply her deodorant at that time. I have recommen ded a Dove clinical strength deodorant. In the morning, she may then apply a th in film of the clindamycin lotion to the armpits. I have written her a large bo ttle with one refill. I would also like for both the acne and hidradenitis supp urativa suppression to keep on the doxycycline 100 mg capsules. She may take on e tab p.o. q.d. as this is suppressing the hidradenitis nicely and will continue to be of benefit for acne since she has only been on it for the last two months or so. I have written her for 90 tablets with one refill. The patient s mother who accompanies her in office today states that they maybe moving out of the sta te. I have given them the American Academy of Dermatology web site and have adv ised them they may click on the find a dermatologist link if they are looking fo r a qualified dermatologist in their new residence. For now, the patient can co ntinue on with refills as needed for up to one year until they are able to find care at wherever they have moved to. Follow up indefinite. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Nummular eczema with xerosis. I have given the patient a 60 mg tube of clob etasol 0.05% ointment. She may apply this twice daily as needed for flares, usi ng only when flaring. I have written her for 60 mg tube with one refill and I h ave advised her if this has not improved significantly over the next week to two weeks I would like her to follow up, otherwise follow up will be at her next sk in exam. 2. Lentigo. The patient was reassured regarding the benign nature of these les ions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whe never they are exposed to the sun. 3. Seborrheic keratoses. The patient was informed of the benign nature of thes e lesions and no treatment is necessary at this time. 4. Hemangioma: The benign nature of the lesions was discussed and no treatment is necessary at this time. The patient states she maybe moving out of town. We will set her recommendation for a total skin exam at one year or sooner if she

discovers that the clobetasol ointment is not working satisfactorily for the num mular shape dermatitis on the lower extremities. All patient questions were ans wered and concerns addressed today in the office. I have also advised to use ge neral moisturizer such as Cetaphil, or CeraVe and switching from all scented was h to all free and clear. The patient voiced understanding. Follow up in one ye ar for a total skin exam if she is still on town. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Mary presents to the office today for suture removal on the right u pper back from removal of epidermoid cyst. Pathology results have come back as consistent with epidermoid cyst. The patient states she has had some draining a nd irritation to the area, which had continued on even when she had gone home. She denies any fever, sweats, or chills. OBJECTIVE: On exam, she is a well-developed and well-nourished Caucasian female , in no apparent distress. Patient presents for suture removal. Patient has no complaint about the surgical site and the wound has healed without any complica tion. The wound was cleansed, suture were removed. The patient was instructed to call me if there is any concern about the surgical site in the future. One S teri-Strip was applied given the area of high tension. There was still some gru mous contents removed today in office. I am going let the wound continue to dra in and just close with a Steri-Strip and have the patient come in for a wound ch eck at some point later on this week to ensure it is healing correctly. There i s some erythema noted around the wound extending past 4 mm border. There is no streaking is present and it is not hot to the touch. I am going to go ahead and put her on Keflex 500 mg tablets to take one tab p.o. t.i.d. for seven days. F ollow up will be in approximately four to five days for a wound check. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Nadia presents accompanied by her mother today for a rash of concer n. She states she got on June 14/15th. She states this started out as inflamma tory papules on the wrist bilaterally and then extended down to the feet and leg s and now is involving the buttocks region and trunk as well. She has a persona l history of eczema as well as a family history of eczema. She currently uses E ucerin on the skin and had been given a course of Keflex by her primary care pro vider to stave off secondary infection. The patient s mother states no known drug allergies. ASSESSMENT/PLAN: Dermatitis, not otherwise specified. The patient was seen by both myself and Dr. Robert J. Pariser in office today. He believes that this do es indeed look like a viral exanthem in nature, possibly the parvovirus B19 exan them. He has reassured the mother that only symptomatic treatment is necessary at this time. It does not look to be scabies in nature. The Elimite cream was prescribed by a former provider. He has advised the patient to not use the Elim ite cream at this time and instead do a topical hydrocortisone ointment such as Pramosone. I have written the patient for Pramosone ointment 1%/1%. The patient may apply this one to three times daily as needed for flares. I have written h er for 28.4 g tube with one refill. We have also discussed gentle skin care reg imen and how to handle dry skin care. I discussed the importance of using a mil d soap in the bath or shower such as Dove for sensitive skin, Oil of Olay, CeraV e or Cetaphil. We also talked about avoiding hot showers or baths and applying a thick emollient cream within three minutes of exiting the bath or shower while the skin is still damp. The patient denies any new foods and cannot remember a ny triggers on the 14 or 15 of June, which makes it even more likely that this i s indeed viral in nature and will burn itself off over the next few weeks or so. When putting the medicine on the hands, I have advised that something else wil l need to be in the child s mouth to occupy her sucking reflex and also mitts will need to be applied to the hands so that hand-mouth contact will be avoided. Mo ther voiced understanding. Follow up will be in approximately three weeks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Mary presents today for a flaking skin condition, which she has had

over the last year. She states it has gotten worse with stress. She has been given Derma-Smoothe oil for the scalp as well as ketoconazole 2% shampoo by a pr evious dermatologist and states that the ketoconazole shampoo has resulted in ac tual worsening of the area and even worse dryness. Of note, she is also getting some increased hair loss noted over the last couple of weeks. The patient give s no family or personal history of eczema or psoriasis. She does drink alcohol. She does not smoke. She is also in today for a couple of areas of concern, co uple on the right and left hip and an area in between the breasts which she woul d like evaluated today too. ASSESSMENT/PLAN: Dermatitis, not otherwise specified, of the scalp and trunk, f ew with a diagnosis of psoriasiform dermatitis, but cannot rule out seborrheic d ermatitis. For now, we will try Taclonex solution to the scalp once daily over the next three to four weeks. Additionally, she will use the Taclonex ointment to the areas on the trunk and arms. For the intertriginous region between the b reasts, I have given her a prescription for Mycolog-II, I would like for her to apply that once or twice daily over the next two to three weeks as well until cl ear. I have discussed with the patient that only biopsy is definitive. If she comes back for follow up and if she has not responded favorably to the Taclonex scalp and ointments, the patient states that she would like to defer biopsy unti l that time. For now, she is going to discontinue the Derma-Smoothe oil and dis continue the ketoconazole shampoo, as it is highly irritating and drying to her. Follow up in approximately three weeks. As this patient is a new patient, I w ould like for her to meet with one of our staff physicians. Follow up will be t hen in approximately three to four weeks with one of our staff physicians. Various options were discussed with the patient to include biopsying the scalp i n office today and treating with Taclonex. Following up in two weeks and then g oing over biopsy results versus treating with Taclonex anyway and to see if it i s steroid responsive and then meeting back up in two weeks and determining wheth er or not there is response to Taclonex and if there is biopsying at that time. The patient has chosen to treat with topicals foregoing biopsy until the two or three week followup. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Yeast folliculitis of the forehead with dryness of the scalp. The patient m ay continue on with the ketoconazole shampoo twice weekly as a maintenance regim en, leave on five minutes and rinse as the scalp soaking shampoo and facial wash . I have written her for a 120 cc bottle with unlimited refills. 2. Acne vulgaris with postinflammatory changes and some patchy xerosis of the f ace. The patient will continue on with clindamycin lotion q a.m. I have writte n her for a large bottle with couple of refills today of the clindamycin lotion as well as the Differin 0.3% gel. I have written her for large tube with one re fill today, which should get her through the next few months. For the dryness, she may wish to use the CeraVe. She will continue on with the CeraVe a.m. and p .m. facial moisturizers and continue on with the CeraVe foaming face wash for he r daily facial wash. Follow up will be in approximately nine months. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. History of malignant melanoma. Scar on the left upper extremity from surger y back in July of 2011, shows no signs of recurrence at today s visit. Today I re viewed sun protection guidelines. I discussed ABCD s and the use of sunscreen. I a lso recommended monthly self skin exam. The patient understands we should be not ified for any changing lesions, new, or concerning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours. We discussed monthly skin checks, looking for any new or changing pigmented lesi ons. We also asked the patient to look for an irregular border, asymmetry, chan ge in color or increase in diameter of any pigmented lesion. 2. Lentigo. The patient was reassured regarding the benign nature of these les ions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whe never they are exposed to the sun.

3. Seborrheic keratoses. The patient was informed of the benign nature of thes e lesions and no treatment is necessary at this time. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Suzanne presents today for a total skin exam. The patient has a hi story of basal cell carcinoma on the nose. She currently uses SPF 50 and spends a lot of time in the garden. She states her father has had some non-melanoma t ype skin cancers removed in the past. She admits to blistering sunburns as a ch ild, but has never used a tanning bed. 1. History of basal cell carcinoma with well healed scar at the nasal tip with zero signs of recurrence. We discussed monthly skin checks, looking for any new or changing pigmented lesions. We also asked the patient to look for an irregu lar border, asymmetry, change in color or increase in diameter of any pigmented lesion. Today I reviewed sun protection guidelines. I discussed ABCD's and the use of sunscreen. I also recommended monthly self skin exam. The patient underst ands we should be notified for any changing lesions, new, or concerning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours. 2. Seborrheic keratoses. The patient was informed of the benign nature of thes e lesions and no treatment is necessary at this time. 3. Lentigo. The patient was reassured regarding the benign nature of these les ions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whe never they are exposed to the sun. 4. Telangiectasia. I explained to the patient the benign nature of this condit ion and discussed options for cosmetic treatment. No treatment was performed du ring today's visit. Follow up will be in approximately one year for her next to tal skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\patricia jill samples consolidated\06-19-12\061912 pjl.doc 7/28/2012 1:02: 31 PM 121856 SUBJECTIVE: Jessica presents to the office today for followup of her acne vulga ris. She is apparently using CeraVe foaming face wash q. a.m. and q. p.m., taki ng one Doryx tablet p.o. q.d. and using Atralin gel pea size amount q. h.s. The patient states that things are better and she is using everything as directed. She does state she does continue to get some persistent pesky breakouts on the chin. ASSESSMENT/PLAN: Acne vulgaris with postinflammatory changes. We will add on a topical benzoyl peroxide/clindamycin combo to her a.m. routine. This will be A canya gel, which she will apply _____ into a thin film on the face q. a.m. after using the CeraVe foaming face wash. She will continue on with the Doryx, a 90day supply was written in the office today. Side effects of the doxycycline the rapy were revisited with the patient. She voiced understanding. She will also continue on with the Atralin gel use q. h.s. The patient will use CeraVe a.m. o r p.m. for moisturization and to offset the irritation, which the Retin-A may in deed cause. I have written her for a 50-gram pump of Acanya with two refills, a large tube of Atralin with two refills, and a 90-day supply of Doryx. We will followup in approximately three months to discuss tapering down the Doryx to a l ow dose of 40 mg or discontinuing altogether depending on her clearance. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: Physical exam reveals a well-developed, well-nourished Caucasian mal e, in no apparent distress. He does have some salmon pink plaques ranging in di ameter from dime size to half dollar size and larger present on the lower extrem ities with some dime to quarter size plaques present on the bilateral upper extr emities as well and some quarter size in diameter lesions present on the scalp w ith silvery scale present. On examination of the nails, he now has pitting invo

lvement to include four nails, the second and third digits of the right hand and the third and fourth digits of the left hand. The patient does state arthritis involvement on the right shoulder. He states he is unwilling to do light thera py due to the 66 mile drive now that he is over in the Suffolk area. He states he is unable to come in three times a week that it will interfere with his work schedule. He also states that he drinks three beers daily and does not intend t o quit making him an unlikely candidate for methotrexate therapy. I have asked the patient if he wish to initiate Humira therapy as the criteria now is that th e patient only need to be a candidate for light and methotrexate therapy, which he would be, given his scalp type involvement and resistant plaques on the arms and legs, despite use of the Taclonex use once daily. We will go ahead and init iate a prior authorization for Humira injectable therapy. I have advised the pa tient that once we hear back whether yes or no we will be in touch with him. Of note, the patient does state that he has a recent PPD on file, performed a coup le of months ago at his primary care doctor s office. I have had Allie Bailey der matology assistant here at Pariser call Dr. Joy Gianvittorio s office to have that faxed over to our office to have on file pending preauthorization. With regard s to medication reviewed, the patient is only on Uroxatral q.d. He has no know drug allergies. Because he does have arthritis involvement, scalp involvement, pitting nail changes, and is having failure with high strength topicals, I do fe el like it is time now to move on to injectable therapy. Education paperwork fo r Humira done today and followup will be pending his insurance decision of the H umira prior authorization. He also does have on the sun exposed areas of the fa ce, neck, and chest some light-tan and light-brown macules of various shapes and sizes consistent with solar lentigines. 2. Lentigo: The patient was reassured regarding the benign nature of these les ions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whe never they are exposed to the sun. Followup open-ended pending Humira prior aut horization decision from his insurance company. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Allie is an employee of Pariser Dermatology, presenting today for B otox for hyperhidrosis in the bilateral axillary region. The patient denies pre gnancy and states no problems in the armpit region today. ASSESSMENT/PLAN: Axillary hyperhidrosis, treated today with Botox for hyperhidr osis. Under aseptic technique, a total of 50 units were injected into the right axillary vault, a total of 50 units were then injected into the left axillary v ault. The patient tolerated the procedure well with minimal bruising or bleedin g. Botox is diluted 100U/4.0ml dilution of saline. The affected area was divide d into a grid pattern with each injection site being approximately 1-2cm apart. Explanation regarding the dispersion of Botox being 1-2cm when placed intra-der mally was provided. Under anti-septic precautions, using a 30-gauge needle, Bot ox is injected intradermally into the bilateral axilla ensuring that a bleb is r aised. Injections were spread out evenly, starting from the periphery and moving to the center, ensuring even coverage of the injections. Explanation provided r egarding perceived benefit within 1-2 weeks and duration of relief from 6-14 mon ths. No charge was incurred at today s visit as this was reconstituted Botox for hyperhidrosis that had been a private supply of Dr. David s used for training. Al lie is a part of employee training today, again no charge incurred. We will fol low up with Allie on an open-ended basis pending breakthrough sweating. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Irritant contact dermatitis to the dorsum of the left forearm, residual mild hyperpigmentation all that is noted today. The patient was given samples to us e p.r.n. flares, but I had advised her if she feels it is triggered by the sun t o make sure she is using good sunscreen to the area at least once or twice daily . Some samples of the Neutrogena Healthy Defense SPF 85 lotion were given to th e patient _____ for her to use, apply in the morning and also apply at lunchtime .

2. Tinea corporis with impetiginization of the bilateral axillary vaults. The patient has finished a course of Keflex for ten days as well as a three-week cou rse of Lamisil and is continuing to experience hyperpigmented plaques with some hyperkeratotic nature to them. The patient was examined by both myself and Dr. David Pariser in the office today. She is advised for a punch biopsy to be done of one of the more hyperkeratotic regions of the right axillary vault. Of note , the patient denies any personal or family history of lupus. She denies any pe rsonal or family history of psoriasis. The diagnosis today is dermatitis, not o therwise unspecified; rule out psoriasiform dermatitis versus fungal versus lupu s versus other. After obtaining written consent, the patient was prepped with alcohol. Buffered Lidocaine with epinephrine 1% was administered for local anesthesia. The specim en was obtained with a 4 mm punch biopsy. 4-0 nylon suture was placed. Drysol was used for hemostasis. Polysporin ointment was applied and the wound was band aged. Wound care instructions were reviewed. The patient tolerated the procedu re well. Pathology results will be mailed to the patient. I have advised the p atient to follow up with me approximately in 10-14 days for suture removal and t he pathology results will take up to 14 days to be returned. At that time, we w ill be contacting her. Followup will be open-ended depending pathology results. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Tracy presents to the office today for a recheck on the melanoma si te, which was removed by Dr. Roger Perry in March of 2012 and repaired by a loca l plastic surgeon. The patient states that the sentinel node biopsy had come ba ck as negative. She is in today for a recheck of the scar on the left shin wher e the melanoma was removed as well as a couple of areas of concern in the groin region and the right medial shin. The patient does admit to an extensive amount of sun exposure as a child as well as tanning bed use. OBJECTIVE: On exam, she is a well-developed, well-nourished Fitzpatrick type 3 female, in no acute distress, alter and oriented. The patient was examined from head to toe to include the scalp, face, neck, trunk, and bilateral upper and lo wer extremities including the buttocks and genital region. On the sun exposed a reas of the upper and lower body including the face, she does have numerous ligh t-tan and light-brown macules of various shapes and sizes consistent with solar lentigo. She points to an area of concern on the medial aspect of the right shi n, which is a pink _____ papule consistent with lichenoid keratosis, confirmed t oday by Dr. Molly K. Smith in office. She also has on the left shin a well-heal ed, well-approximated scar with no sign of residual tumor noted today in office, again this was confirmed by Dr. Molly K. Smith on exam and myself. The patient points to some areas of concern in the genital region. On the left external la bia, there are couple of fleshy pedunculated growths, a couple also almost comed onal in nature, likely skin tag, but cannot rule out HPV. The patient s options w ere discussed to include biopsy of the region and/or treatment via cryotherapy. Because the patient is getting married in two weeks, she wishes to defer any ty pe of biopsy and/or treatment until her three-month followup. 1. History of malignant melanoma. Today I reviewed sun protection guidelines. I discussed ABCD s and the use of sunscreen. I also recommended monthly self skin exam. The patient understands we should be notified for any changing lesions, ne w, or concerning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours. We discussed monthly skin checks, looking for any new or changing pigmented lesions. We also asked the patient to look for an irregular border, asymmetry, change in color or increase in diamete r of any pigmented lesion. Followup will be every three months over the next ni ne months and then we will go to six-month surveillance for the following two ye ars. 2. Neoplasm, uncertain in the genital region left labial/perineal area, likely a skin tag versus HPV. The patient opts to do a biopsy of this region after her wedding. She is agreed to do this at the three-month followup for her melanoma check. 3. Seborrheic keratoses. The patient was informed of the benign nature of thes

e lesions and no treatment is necessary at this time. 4. Lentigo: The patient was reassured regarding the benign nature of these les ions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad- spectrum sunscreen with an SPF 30 or greater whe never they are exposed to the sun. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Aubrey presents today as a new patient with the rash that has been bothering her over the last three weeks. It was diagnosed by her pediatrician a s poison ivy. She has had this rash approximately three weeks. She has been us ing calamine as well as Bactine spray. The patient s mother who accompanies her t oday states that after she was treated by her pediatrician, she had developed so me pinpoint papules spread out over the arms, legs, and central chest, which hav e become itchy to the patient. This was after discontinuing an oral prednisone taper. The patient s mother gives no personal or family history of skin problems in the past. She is currently not taking any pills nor is she allergic to any m edications that she knows of. ASSESSMENT/PLAN: Dermatitis, not otherwise specified, likely result of the alle rgic contact dermatitis initially started on the back. I am going to treat the body with triamcinolone cream 0.1%, a 60 g tube to be applied twice daily over t he next two weeks. Additionally for the couple of pinpoint papules present on t he bilateral cheeks region, I am going to have the patient apply desonide lotion to the face twice daily p.r.n. flares over the next two weeks until followup. Side effects of the topical steroids were discussed with the mother and patient in office today. They voiced understanding. She is to only use this when neede d for symptomatic itch/flares and discontinue if she has noted improvement befor e her two-week followup. The patient and mother have also been instructed they are only to apply this on the affected areas. Follow up will be in two weeks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Michelle presents today for psoriasis followup. She has finished a pproximately 12 UVB treatments and states no change in the amount or appearance of her psoriatic plaques. In fact, she states that she is now having some plaqu es on the arms and legs that are bleeding. The patient is continuing to do topi cal clobetasol therapy twice daily in addition to her UVB light treatments. She states she is worried that she is getting Cushing syndrome due to the fact that she has new onset vertigo with some blurry vision and noted fatigue and depress ion. The patient s history includes arthritis in both the feet and the lower extr emities bilaterally. She has pitting nail changes in both index fingers of the right and left hand. Involvement encompasses the following. On the scalp, ears , and nasal alae, she does have guttate two half-dollar sized plaques on the elb ows bilaterally, dime-sized to quarter-sized plaques with silvery scale. She ha s guttate-sized plaques present on the arm. On the legs, she does have approxim ately 8-9 quarter-sized plaques, some of which are larger in diameter. She has extensive involvement of the groin folds with well-demarcated erythema present, consistent with inverse psoriasis. This is present in the arm pits as well alon g with some raised plaques with slivery scale. In the inframammary region, she also does have evidence of inverse psoriasis involvement. There are some half-d ollar sized plaques apparent on the abdomen and back as well with silvery scale and involvement of the gluteal cleft. The patient drinks approximately 5-6 drin ks per week, therefore, she is not a viable candidate for methotrexate therapy. She has failed the UVB light treatment thus far. I would like to move to injec table approval as fast as possible given her joint pain symptoms and extensive i nverse and scalp involvement. We are going to reinitiate prior auth for Enbrel. If the Enbrel is not able to get approved, we will at that time consider initi ating a prior authorization for Humira. Other than the psoriatic plaques on exa m, she does have some scattered benign symmetrical-appearing nevi 2-3 mm in size , light brown and evenly pigmented on the bilateral upper and lower extremities and the trunk and neck region as well. ASSESSMENT/PLAN: Psoriasis with xerosis with plaque-type psoriasis and inverse

involvement to include the scalp, groin, gluteal cleft, and armpit region. The patient has failed 12 visits of light therapy with no noted improvement, in fact has reported worsening. She is also noticing some what she believes to be side effects from extensive potent topical steroid use twice daily over the last yea r. I would like to move to injectable therapy as soon as possible given that sh e is a 5-6 drinks per week drinker, methotrexate is not an option at this time, move to prior auth of injectable biologic therapy Enbrel. If no luck with Enbre l, we will consider initiating prior auth for Humira. Follow up will be pending decision of her insurance. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Chad presents to the office today as a new patient for an itchy red rash he has had over the last few years. He does give a family history of his brother having a similar itchy red rash. Primary care doctor had recommend Sels un Blue in the past. He states that this actually lined up the areas that he ha d applied it on as a body wash. The patient denies any personal or family histo ry of psoriasis, though he does have a brother with extremely sensitive dry skin . He is not sure if it is eczema or not. He is a nondrinker. He does smoke to bacco. ASSESSMENT/PLAN: Dermatitis, not otherwise specified, favor the diagnosis of se borrheic dermatitis. I am going to put the patient on a two-week trial of ketoc onazole shampoo to apply to the backs of the ears and base of the neck (affected areas), leave on for 5 minutes in the shower and then rinse daily for a period of two weeks. If this does help to quell the inflammatory response, I would lik e for him to continue on with the maintenance regimen of using the ketoconazole shampoo as the body wash twice weekly. For inflammatory outbreaks, I would like for him to apply Topicort-LP to the affected areas of the base of the neck and also in the couple of patchy areas of erythema in the bilateral popliteal fossa, again twice daily only as needed for flares and only when symptomatic to the af fected areas. Side effects of the topical steroid were discussed with the patie nt in office today. He voiced understanding. We will follow up in approximatel y three weeks to reassess. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Nina presents to the office today for some areas and/or growths of concern on the legs as well as one on the left forearm and one on the right hand , which bother her in appearance. She gives no family history of skin problems. No personal history of skin cancer. She has had some benign lesions frozen of f in the past. She is currently being treated by other physicians for diabetes, cholesterol, reflux, interstitial cystitis, and depression. She is currently o n glimepiride, simvastatin, Nexium, Zoloft, and Almiron. She is an occasional d rinker. She is a nonsmoker. The patient does admit to excessive sun exposure a s a child, but cannot remember any sunburns. She also denies tanning bed use. 1. Neoplasm uncertain on the volar aspect of the right upper extremity, rul e out verrucous keratosis versus SCC. After obtaining written consent, the pati ent was prepped with alcohol. Buffered lidocaine with epinephrine 1% was admini stered for local anesthesia. The lesion was removed in its entirety via a shave procedure with a Dermablade. Drysol was used for hemostasis. Polysporin ointm ent was applied and the wound was bandaged. Wound care instructions were review ed. The patient tolerated the procedure well. Pathology results will be mailed to the patient. 2. Neoplasm uncertain diagnosis on the dorsum of left hand, rule out verruc ous keratosis versus SCC. After obtaining written consent, the patient was prep ped with alcohol. Buffered lidocaine with epinephrine 1% was administered for l ocal anesthesia. The lesion was removed in its entirety via a shave procedure w ith a Dermablade. Drysol was used for hemostasis. Polysporin ointment was appl ied and the wound was bandaged. Wound care instructions were reviewed. The pat ient tolerated the procedure well. Pathology results will be mailed to the pati ent. 3. Sun damage. The importance of daily sun protection was discussed. The p

atient was given an informational brochure on skin cancer and a starter sample o f a complete sun block. 4. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 5. Seborrheic keratoses. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. 6. Home Skin Exam. We discussed monthly skin checks, looking for any new o r changing pigmented lesions. We also asked the patient to look for an irregula r border, asymmetry, change in color or increase in diameter of any pigmented le sion. Today I reviewed sun protection guidelines. I discussed ABCD s and the use of sunscreen. I also recommended monthly self skin exam. The patient understa nds we should be notified for any changing lesions, new, or concerning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours. 7. Follow up will be pending pathology results available in two weeks, othe rwise providing all results come back as benign, we will see the patient back in one year for another total skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Ruel presents to the office today for what he believes to be eczema of the five fingers of his right hand and his third and fourth digit of his lef t hand. He also is getting some involvement under the eyes to include thickenin g and darkening of the skin at the medial canthi bilaterally. He states he has had this since April of 2012. He has been given a topical steroid by his primar y care provider, he is unsure what the name of the steroid is. The patient is t he patient of Dr. Donald Curtis. He is currently using and he has used in the p ast as well A&D ointment, over-the-counter hydrocortisone, and Lotrimin. He giv es a past history of allergies and eczema. He is a nondrinker and nonsmoker. H e was never used to tanning bed. ASSESSMENT/PLAN: Dermatitis, not otherwise specified, possible ICD versus rule out fungal. I have spoken with Dr. Molly Smith regarding this patient. She has advised a fungal culture, which we have done in office today of the right third and fourth digits. This was done by dermatology assistant, Allie Bailey. For the hands, we are going to do Lotrisone 1% cream to apply to the affected areas of hands twice daily, I have written him for 60 g tube with one refill and we wi ll see him back in two weeks. For the hyperpigmented thickened areas in the eye s, she has recommended Protopic 0.03% ointment to be applied avoiding the mucous membrane of the eyes. This was discussed with the patient as well as to expect a tingling sensation on the first three applications. He understands. Samples of the Protopic 0.03% ointment were given to the patient as well as a prescript ion for the Lotrisone cream. We will see him back in two weeks for reevaluation . Actually, he is not a new patient to the practice, but he has not been seen f or quite some amount of the year, so he is just quoted as a new patient to the p ractice today. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Linda presents to the office today for a couple of areas of concern . There is a birth spot on the nasal tip; she would like evaluated today as wel l as some rough spots around the ankles. She also has an area of concern on the right posterior calf, which is somewhat dry in nature. The patient states that she has a history of some skin cancers removed; she is unsure which type by a p revious provider. She has a history of seasonal allergies and is an occasional drinker and nonsmoker. She does admit to cumulative sun exposure as a child wit h some blistering sunburns. 1. Actinic keratosis on the nasal tip. The patient wishes to defer treatment u ntil her total skin exam, which she is going to follow up within three weeks. S he states she has prior engagement and she does not want a scabby appearance dur ing that time. Followup in three weeks.

2. Verruca plana. I have written the patient for a 40% Urea cream, a large tub e with one refill. She may apply this twice daily to the affected areas of the feet around the heels. 3. Irritated lentigo, posterior aspect of the right calf. This was treated as a courtesy to the patient with liquid nitrogen and cryotherapy x2 cycles. P ostprocedural care and expectations were discussed with the patient. She tolera ted the procedure well. Followup in three weeks for total skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Sunceray presents to the office today for complaints of acne with s ubsequent discoloration as well as some hyperlinearity, wrinkles and dryness of the dorsum of the forearms as well as potential facial laser hair removal. She states all of them bother her in appearance and she states she has had these con ditions for as long as she can remember. The patient denies any personal histor y of skin problems, but states her sister has a history of rashes. She is current ly using Clinique acne treatment and skin lightener, which is the Proactiv spot remover, but states that it makes the skin too light around the surrounding area . ASSESSMENT/PLAN: Acne vulgaris with postinflammatory changes, facial involvemen t. Trunk is spared. I have told the patient she may opt to continue on with Cl inique acne products in the morning and then at night I would like for her to st art with the Differin 0.3% gel for her mild case of acne, she may apply this pea size amount every other night titrating up to nightly use as tolerated. I have written her for a 45 g pump. We have also discussed future options such as che mical peels. I have gone over both the glycolic acid and salicylic acid treatme nts as well as the price and price before a package in addition or otherwise she may opt to do laser treatment of some of the discoloration if such treatment is available. For laser tanning and facial hair laser removal, I have referred he r to Dr. Chang for a cosmetic consult. A price list and an informative brochure for Dr. Chang was given to the patient in office today. Cosmetic consult will be scheduled upon her exit today. For the hyperlinearity and xerosis of the dor sum of the hands, I have recommended patient discontinue her current therapy of nut butters to the hands as the fragrance and ingredients can be somewhat harsh and instead use a moisturizer and wash specifically formulated for atopic skin. I have given her coupons for Cetaphil RESTORADERM lotion in office today as well as the body wash and had her apply tester amount of the RESTORADERM lotion to t he hands in office today as samples to take home were unavailable. I have also stressed with the patient the use of good sunscreen to avoid further new hyperpi gmented lesions. The importance of daily sun protection was discussed. The pati ent was given an informational brochure on skin cancer and a starter sample of a complete sun block. . I have advised the patient that we will follow up in ap proximately three months for the acne. At that time, if she wishes to become mo re aggressive, I am happy to discuss and revisit alternative treatment options s uch as peels. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Ms. Hoffman presents to the office today for wound check of the tib ial surface where she had an ED&C done removing the rest of her bowenoid squamou s cell carcinoma in situ, which was biopsy-proven back in May 2012. The patient states it has been somewhat hot and pus-like in nature. She is in today to hav e it evaluated as well as a couple other areas of concern. The patient denies a ny fevers, sweats, or chills since last date of appointment 06/06/2012. 1. Pigmented actinic keratosis, left volar forearm. Treated in the office today with liquid nitrogen cryotherapy x2 cycles. Postprocedural care and expec tations were discussed with the patient. She tolerated the procedure well. 2. Insect bite reaction, posterior aspect of the right calf. I have given the patient some samples of Aveeno, she may use this twice daily for help with i nflammation over the next week. 3. Ulcer on the left shin, healing appropriately. I have given the patient some Biafine emulsion, which she may apply to the area twice daily. She states

it has improved over the last 24 hours. We will follow up with her in approxim ately four weeks for a wound check of this region. 4. History of BCC. We discussed monthly skin checks, looking for any new o r changing pigmented lesions. We also asked the patient to look for an irregula r border, asymmetry, change in color or increase in diameter of any pigmented le sion. Today I reviewed sun protection guidelines. I discussed ABCD s and the use of sunscreen. I also recommended monthly self skin exam. The patient understan ds we should be notified for any changing lesions, new, or concerning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at th e peak sun hours. Follow up in four weeks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. MEDICATIONS: The patient s medications were reviewed. She has no medication chan ges. She has had over the last year a hive-like reaction to pineapples. OBJECTIVE: Physical examination reveals a well-developed, well-nourished thin C aucasian female, in no apparent distress. I did examine today the scalp, face, neck, trunk and bilateral upper and lower extremities today including the buttoc ks region. On the right nasal sidewall, she does have a persistent ill-defined waxy plaque suspicious for actinic keratosis. The patient states that she has n ot noticed any flaking in the region and states that it is asymptomatic. She wi shes to leave alone at this time. All the treatment options were offered to inc lude cryotherapy as well as Solaraze therapy. The patient wishes to defer until the region does become symptomatic. On examination of the sun-exposed areas of the upper and lower body and especially the back, she has numerous light tan an d light brown macules. Shapes and sizes are consistent with solar lentigines an d couple of waxy stuck-on appearing papules light tan to light brown in nature c onsistent of seborrheic keratosis. There were also some generalized fine flakin g of the plantar aspects of the feet bilaterally consistent with xerosis. 1. Actinic keratosis, right nasal sidewall. The patient will watch and ret urn to the office as needed for treatment if symptomatic. 2. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 3. Seborrheic keratoses. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. 4. Xerosis. I discussed the importance of using a very mild soap in the ba th or shower such as Dove for sensitive skin, Oil of Olay, or Cetaphil. We also talked about the importance of moisturizing directly after the bath or shower, when the skin is still damp, with a thick emollient cream such as Cetaphil Cream or Vaseline Creamy Formula. Follow up will be open-ended per the patient s reque st. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Seborrheic keratoses on the left occiput scalp. I have advised the pati ent this is benign in nature. If it continuously be traumatized and she wished to remove, I am happy to do this for no charge via liquid nitrogen cryotherapy x 3 cycles and it was to be determined by the patient. 2. Xerosis of the scalp. The patient will continue with her zinc pyrithion e or T-gel shampoo used once every other week. 3. Hyperpigmentation of the bilateral axillary vaults. I have discussed wi th the patient that she may wish to do Ambi Fade skin bleach 2% over-the-counter . We have discussed use and contraindications as well as doses and administrati on today in office and side effects. The patient voiced understanding. Follow up will be open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SOCIAL HISTORY: She has never been in the tanning bed and is a nondrinker and n onsmoker. Her biggest concern is discoloration that the inflammatory papules ar ound the chin are causing once they are in the stages of resolution. That is wh

y she presents today for a salicylic acid peel for her acne. Consent was signed and scanned into the patient correspondence file today. The patient denies any use of Retin-A over the last 48 hours. ASSESSMENT/PLAN: Salicylic acid peel for the patient s acne vulgaris with postinf lammatory hyperpigmentation. The skin was cleansed with CeraVe hydrating facial cleanser and then pat it dry. After that, it was defatted with a sterile alcoh ol swab. The 30% salicylic acid solution was then applied to the face and left on to sit approximately 2 minutes and 40 seconds, at which time the frosting occ urred. It was then neutralized with sterile water and Aveeno calming daily mois turizer was applied with SPF 30. The patient was advised not to use or exfoliat e over the next week or any toner to the area. She will simply continue on with a daily gentle hydrating wash such as CeraVe and a good sunscreen over the next week. Coverage codes today per anthem are 15,788 and/or 15,786, again this is suppose to be covered under the patient s insurance per the patient. I have advis ed Carmela to expect some mild erythema with fine flaking and I have given her a post peel care instruction sheet. She will follow up with us on an open-ended basis. I have recommended a series of three to four peels spaced out four weeks apart. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. 1. Allergic contact dermatitis likely secondary to chemical blocker ingredi ents. We are going to try physical blocker such as zinc oxide. I have given th e patient some suggestions of some zinc oxide physical blockers and discussed wi th her that she is to do a patch test on the inner arm and leave on for 48 hours to see if there is any type of reaction noted at that time. The difference bet ween chemical blockers and physical blockers was discussed with the patient in o ffice today. Should she continue to experience skin irritation with use of the physical blocker such as zinc oxide and titanium dioxide, then we will have her come back in for a possible patch testing in the future. A patch testing educat ional and informational brochure was given to the patient in the office today fo r her to read. 2. Scalp psoriasis with xerosis. The patient s refill for clobetasol was giv en at today s visit, a 100 g can, she is to apply this to the affected areas of th e scalp once nightly p.r.n. flares. I have also written her for two refills. T he only current medication the patient does on is Celexa. The importance of dai ly sun protection was discussed. The patient was given an informational brochure on skin cancer and a starter sample of a complete sun block. Follow up at this time will remain open-ended. Of note, the patient stated that she did have trouble getting in to be seen on a n emergent basis with one of the providers. I have advised the patient to ask t he phone room staff to please lookup this visit note and I have requested that i f the patient does have an acute outbreak that she be seen emergently on a fit-i n basis per my request. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. SUBJECTIVE: Michelle presents to the office today for followup of lesion of con cern on the posterior aspect of the right calf. The patient has a history of at ypical nevus removed on the right medial thigh. She is in today for her six-mon th total skin exam and also because she has noticed one of the ones we have watc hed on the right calf has grown on both sides and _____ per the patient. The pa tient does admit to tanning bed use more than 20 times in her life at age 18. S he denies any blistering sunburns as a child. OBJECTIVE: On exam, she is a well-developed, well-nourished Caucasian female, i n no apparent distress. On examination on the posterior aspect of the right cal f, there is a 7-mm medium brown macule well-circumscribed and evenly pigmented. Per the patient s history of atypical nevi and increase in size and darkening, I am going to remove today, ruling out atypical nevus versus dysplastic nevus. ASSESSMENT/PLAN: Neoplasm uncertain, rule out AN versus DN. After obtaining a written consent, the patient was prepped with alcohol. Buffered lidocaine with epinephrine 1% was administered for local anesthesia. The lesion was biopsied v

ia a shave technique using a Dermablade. Drysol was used for hemostasis. Polys porin ointment was applied to the wound and covered with a bandage. Wound care was reviewed. The patient tolerated the procedure well. Pathology results will be mailed to the patient. We will follow up with the patient in approximately six months for another total skin exam unless pathology dictates that we see her sooner. I have advised the patient pathology will be available in approximatel y two weeks. We will be in touch at that time. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. OBJECTIVE: On examination, she is a well-developed, well-nourished Caucasian fe male, in no apparent distress. I did examine both the face and the perirectal a rea today. On the face, she does have some erythema in the forehead and bilater al malar cheek region of the face with some fine flaking, which looks to be more consistent with seborrheic dermatitis type of condition, although she does have a few inflammatory papules noted in the same area, which could be also superimp osed papular-type rosacea. On examination of the perirectal region, there is a well-demarcated area of erythema. No inflammatory pustules are noted. It does not look to be infectious, but rather inflammatory. The area was examined by bo th myself and Dr. David Pariser today. He does believe that this is more consis tent with inflammatory process such as intertrigo. On perirectal region, _____ mons and labial region is spared of any inflammation. Again, this does not like to be infectious in nature. The patient was reassured of this. 1. Dermatitis, not otherwise specified of the face. I would like to treat initially for seborrhea over the next couple of weeks. I have given the patient 60-g tube of ketoconazole 2% cream. I would like her to apply this to the face q.a.m. and at night apply desonide lotion to the face. I have written her for 60-g tube of each. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\patricia jill samples consolidated\06-19-12\received on 07-09-12\061912 pjl.do c 7/28/2012 1:02:31 PM 37888 SUBJECTIVE: Mr. Jefferson presents to the office today for suture removal. He denies any fevers, sweats, or chills since date of biopsy and denies any oozing, bleeding, crusting, or drainage from the wound site. On the left jaw, there is a well-healed, well-approximated wound. The patient presents for suture remova l. Patient has no complaints about the surgical site, and the wound has healed without any complication. The wound was cleansed and sutures were removed. Th e patient was instructed to call me if there is any concern about the surgical s ite in the future. Follow up will be pending pathology results. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_002_004 brubaker, megan d._072512.doc 7/30/2012 8:39:33 PM 40448 1. Acne vulgaris. Comedonal in nature mainly on the forehead. The patient states that the doxycycline she is using for her PLC does a good job of keeping most of her acneiform lesions at bay. I have written her for refill of doxycyc line 50 mg cap, she is to take one cap p.o. q.d. I have written her for 30 with five refills. She may call in for up to a year's worth of refills. I did refi ll Megan s prescription for Atralin gel at her request after the appointment. The patient has requested a tube of Atralin gel to be prescribed. I have written h er for a 45-gram tube of the Atralin pea-size amount to face every other night, titrating up to nightly use as tolerated, 45-gram tube with two refills. This s hould get her through the year nicely. 2. Benign nevi. These are all well marginated, homogenously pigmented, sym metrical, benign appearing moles. We reviewed the ABCDs of melanoma, and a hand out detailing this information was given to the patient. The patient understand

s that if any of these lesions begins to change, they are to return to clinic fo r re-evaluation. 3. Verruca right middle finger, plantar aspect. This lesion was treated wi th liquid nitrogen cryotherapy x3 cycles. Postprocedural care and expectations were discussed with the patient. She tolerated the procedure well. We will fol low back up with the patient in approximately one year for her next total skin e xam unless of course she needs us sooner. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_003_brubaker, shirley_072512.doc 7/30/2012 8:39:33 PM 419 84 CURRENT MEDICATIONS: The patient is on amitriptyline and Ortho Tri-Cyclen. 1. Verruca. Three were treated in office today, two on the left leg, one o n the right leg with liquid nitrogen cryotherapy x3 cycles. Postprocedural care and expectations were discussed with the patient. She tolerated the procedure well. 2. Lentigo. The patient was reassured that these are benign lesions. They do however, indicate diffuse sun damage. We discussed the importance of wearin g a broad- spectrum sunscreen with an SPF of 30 or greater whenever she is expos ed to the sun. A handout of recommended broad-spectrum sunscreens was given to the patient as well as numerous broad-spectrum sunscreen samples. 3. Seborrheic keratosis. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. 4. Benign nevi. These are all well marginated, homogenously pigmented, sym metrical, benign appearing moles. We reviewed the ABCD s of melanoma, and a hando ut detailing this information was given to the patient. The patient understands that if any of these lesions begin to change, they are to return to clinic for re-evaluation. 5. Skin tags. Two were frozen with liquid nitrogen cryotherapy x2 cycles a s a courtesy to the patient in office today. She tolerated the procedure well. 6. Tinea versicolor on the back. The patient states she has done ketoconaz ole orally in the past with good results. Therefore, I filled the prescription for ketoconazole 200 mg tabs one tab p.o. q.d. for 10 days with no refills. The patient knows to workout after approximately one hour after taking the pill. S he voiced understanding. 7. History of BCC. We discussed monthly skin checks, looking for any new o r changing pigmented lesions. We also asked the patient to look for an irregula r border, asymmetry, change in color or increase in diameter of any pigmented le sion. Today I reviewed sun protection guidelines. I discussed ABCD's and the use of sunscreen. I also recommended monthly self skin exam. The patient understand s we should be notified for any changing lesions, new, or concerning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours. We will see her back for followup in six months given her past recent history of skin cancer. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_005_carlisle, donshawnique_072512.doc 7/30/2012 8:39:32 PM 39424 ASSESSMENT/PLAN: Acne vulgaris with postinflammatory hyperpigmentation and some small cystic involvement most notably along the chin and jawline. An acne regi men was developed for the patient today to include Benzamycin use q.a.m. and dox ycycline 100 mg tablets one p.o. b.i.d., I have written her for 30 with two refi lls. This will give her a 90-day supply and then at night, she is to do a pea-s ize amount of Differin gel to the face. Side effects of doxycycline, Benzamycin and Differin gel were discussed with the patient in office and reviewed. She v oiced understanding. Additional 20 minutes was spent going over in detail with

the patient today. A detailed acne regimen for them to include dosage and admin istration instructions for the cleansers, moisturizers, and prescriptions prescr ibed today. All patient concerns were addressed and patient questions answered. Side effects of the medications were also reviewed with the patient in office today. They voiced understanding. The patient was counseled on the etiology an d course of treatment for acne. I have advised them to expect the acne to get w orse before it gets better. They may expect a flare-up approximately three to f our weeks into treatment and this is normal. I usually will see the patient bac k in two months and have advised compliance for eight consecutive weeks before r eevaluating. The patient voiced understanding of this today in office. Additio nally, over-the-counter Cetaphil foaming face wash and oil-free moisturizer were given to the patient to use in the morning and at night. Follow up in two mont hs. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_006_kliewer, matthew a._072512.doc 7/30/2012 8:39:32 PM 4 4544 SUBJECTIVE: Mr. Kliewer presents to the office today for annual skin exam. He states he had one a couple of years ago. Concerns today include some dryness on the ears, mole check and also some dryness on the feet with what he thinks is a corn on the plantar aspect of the right foot. The patient denies any personal or family history of skin cancer. He does admit to blistering sunburns as a chi ld and denies tanning bed use. He is a nondrinker and a nonsmoker, who is not o n any daily medications nor is he allergic to any medications. OBJECTIVE: On exam, he is a well-developed, well-nourished, thin Caucasian male , in no apparent distress. I did examine today the scalp, face, neck, trunk, an d bilateral upper and lower extremities including the buttocks region. Groin re gion was deferred at today s visit. On examination of the scalp in the vertex reg ion, the patient does point to an area of concern, it is approximately 7-mm ligh t pink papule, rule out AN versus DN versus nevus sebaceous versus BCC. The rea son this is of a concern is the patient does give a history of sunburn to this a rea and did live in Colorado in the high altitude. On examination of the trunk, he has some symmetrical cherry red papules consistent with cherry hemangioma; a few scattered light tan and light brown macules on the upper shoulders consiste nt with solar lentigines. He has a very mild comedonal acne component mainly in the T-zone region of the forehead, nose, and chin and some scattered symmetrica l benign-appearing nevi on the trunk and extremities, 2 to 6 mm in size, a few w ith hazy borders, though this appears to be his normal symmetrical and evenly pi gmented, medium brown is the predominant color. On examination of the lower ext remities, he does have on the plantar surface of the right foot a couple of verr ucous papules consistent with verruca and a large hyperkeratotic area on the bal l of the foot, more consistent with corn. 1. Neoplasm uncertain, rule out atypical nevi versus dysplastic nevi versus nev us sebaceous versus BCC. After obtaining written consent, the patient was prepp ed with alcohol. Buffered lidocaine with epinephrine 1% was administered for lo cal anesthesia. A 3-mm punch biopsy was performed. The biopsy site was closed with sutures. Polysporin ointment was applied and the wound was bandaged. The patient tolerated the procedure without complaint, and wound care instructions w ere given. Pathology results will be mailed to the patient. This was done in t he office today by dermatology technician, Kelly Walker. Wound care was discuss ed with the patient. He understands. 2. Benign nevi. These are all well marginated, homogenously pigmented, symmetr ical, benign appearing moles. We reviewed the ABCD s of melanoma, and a handout d etailing this information was given to the patient. The patient understands tha t if any of these lesions begins to change, they are to return to clinic for reevaluation. 3. Verruca, two on the plantar aspect of the right foot. These were treate d in office today with liquid nitrogen cryotherapy x3 cycles. Postprocedural ca

re and expectations were discussed with the patient. He understands. With rega rds to the corn, Dr. Rolfe has seen this patient with me today and has advised a podiatrist consult for the corn. With regards to his mild case of comedonal ac ne, I have refilled his prescription for Differin gel 45 g pump one pump to face q.h.s. for acne. 5. Lentigo. The patient was reassured that these are benign lesions. They do however, indicate diffuse sun damage. We discussed the importance of wearin g a broad- spectrum sunscreen with an SPF of 30 or greater whenever he is expose d to the sun. A handout of recommended broad-spectrum sunscreens was given to t he patient as well as numerous broad-spectrum sunscreen samples. 6. Xerosis of the feet and ears. The feet have some scaling present today, though it does not look to be fungal or hyperkeratotic in nature, just some gen eralized dryness. No dryness is present on the ears today; however, I have writ ten triamcinolone cream which the patient may use on the external ear, on the bo ttoms of the feet. A 60-gram tube was written with no refills. He may use this twice daily as needed for flares. Side effects of topical steroids use were di scussed with the patient. He voiced understanding. We discussed monthly skin c hecks, looking for any new or changing pigmented lesions. We also asked the pat ient to look for an irregular border, asymmetry, change in color or increase in diameter of any pigmented lesion. Today I reviewed sun protection guidelines. I discussed ABCD's and the use of sunscreen. I also recommended monthly self skin exam. The patient understands we should be notified for any changing lesions, n ew, or concerning lesions. I also discussed the use of wearing a hat and avoidin g outdoor sun exposure at the peak sun hours. We will follow up with Mr. Kliewe r in approximately 10 days for suture removal on the vertex scalp, after that we will see him back annually for a total skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_007_nechamer, lindsey c._072512.doc 7/30/2012 8:39:32 PM 38912 ASSESSMENT/PLAN: Acne vulgaris, postinflammatory changes and scarring. I am go ing to change the patient s acne regimen to incorporate benzoyl peroxide into her clindamycin used. In the morning, we are going to do a prescription for Benzamy cin gel in the hopes that she will be able to be compliant with this one-step re gimen. I have advised her that if she wants to, she may use a gentle wash such as Cetaphil DERMACONTROL oil-free foaming cleanser, a sample was given to her in office today as well as coupons. She may obtain this over-the-counter. At nig ht, she will continue with the tretinoin 0.1% gel pea-size amount to face, the p atient tolerates on a nightly basis. She may continue to use this nightly. I h ave written her for a large tube with four refills which should get her through the year. Follow up at this point is open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_008_rock, marie_072512.doc 7/30/2012 8:39:31 PM 28672 The patient also denies any personal history of skin cancer, but states her dad does have a history of nonmelanoma-type skin cancer as well as her paternal gran dmother dying from skin cancer. She also states her brother has had some melano ma skin cancers removed on the face. OBJECTIVE: On exam, she is a well-developed, well-nourished Caucasian female, i n no apparent distress. I did examine today the scalp, face, neck, trunk and bi lateral upper and lower extremities including the buttocks region. Groin region was deferred at today s office visit. The patient points to an area on the glute al cleft where she has on the left buttock an inflammatory papule which looks to be consistent with a ruptured hair follicle. She also has a couple of inflamma tory papules on the buttocks region consistent with mild case of folliculitis. On examination of the sun exposed areas of the upper and lower body, she has num

erous light tan and light brown macules of various shapes and sizes consistent w ith solar lentigo. She also has some wary waxy stuck-on-appearing papules light tan to light brown in nature consistent with seborrheic keratoses and some symm etrical benign-appearing nevi light brown in nature, 2 to 3 mm in diameter, well pigmented and evenly circumscribed on the arms, legs and trunk. There is a con genital nevus measuring 2.7 cm in diameter. It is medium brown in color and has remained stable all throughout the patient s life. On the left cheek/jaw, she ha s an ill-defined waxy erythematous plaque suspicious for actinic keratosis. She also does have on the dorsal aspect of the left index finger, a 3-mm verrucous papule consistent with verruca. 1. Actinic keratosis, left jaw. This lesion was treated in the office toda y with liquid nitrogen and cryotherapy x2 cycles. Postprocedural care and expec tations were discussed with the patient. She tolerated the procedure well. 2. Verruca, left index finger dorsal aspect. This lesion was treated with liquid nitrogen cryotherapy x3 cycles. Postprocedural care and expectations wer e discussed with the patient. She tolerated the procedure well. Additionally, home wart therapy instructions were offered to the patient. We discussed treati ng the warts by soaking the affected areas in warm water for 15 minutes and then using a pumice stone to help debride some of the dead skin. The patient can th en apply topical salicylic acid liquid to the warts, let dry and cover with duct tape. The duct tape can be removed the following day and the procedure repeate d if necessary. 3. Benign nevi. These are all well marginated, homogenously pigmented, sym metrical, benign appearing moles. We reviewed the ABCD s of melanoma, and a handou t detailing this information was given to the patient. The patient understands t hat if any of these lesions begin to change, they are to return to clinic for re -evaluation. 4. Seborrheic keratosis. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. 5. Lentigo. The patient was reassured that these are benign lesions. They do however, indicate diffuse sun damage. We discussed the importance of wearin g a broad- spectrum sunscreen with an SPF of 30 or greater whenever she is expos ed to the sun. A handout of recommended broad-spectrum sunscreens was given to the patient as well as numerous broad-spectrum sunscreen samples. 6. Folliculitis. I have prescribed the patient two weeks worth of Doryx tab lets, she is to take one by mouth daily for the next two weeks. Side effects of doxycycline therapy were discussed with the patient. She voiced understanding. Instructions for administrations were also given. She understands. Follow up will be in one year for her next total skin exam unless of course she needs it sooner. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_009_macros.doc 7/30/2012 8:39:31 PM 21504 ACTINIC KERATOSIS MACRO: These lesions were treated in office today with liquid nitrogen cryotherapy x2 cycles. Postprocedural care and expectations were disc ussed with the patient. They tolerated the procedure well. VERRUCA MACRO: The verrucae were treated today in office with liquid nitrogen c ryotherapy x3 cycles. Postprocedural care and expectations were discussed with the patient. They tolerated the procedure well. DOXYCYCLINE SIDE EFFECTS MACRO: The side effects of doxycycline were discussed with the patient to include photosensitivity, and stomach upset. The patient ha s been advised to wear sunscreen and physical blockers while exposing themselves to the sun. They have also been informed that if they do in fact experience st omach upset, they may wish to try with a meal although a meal that does not incl ude dairy products such as milk, yogurts, or cheeses. The patient has been info rmed that if they do experience intolerable gastrointestinal upset, nausea, vomi ting or diarrhea, they are to discontinue the medication and call the office at once.

BENZOYL PEROXIDE MACRO: The patient has been informed of of benzoyl peroxide and has been informed that one of the day does contain this ingredient. They have been advised old towels when in contact with this product. They have dry completely before applying or removing clothing.

the bleaching effects products prescribed to to use white towels or been advised to let it

e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_010_eller, garrett r._072512.doc 7/30/2012 8:39:31 PM 240 64 SUBJECTIVE: Garrett presents to the office today for flare-up of folliculitis o n the buttocks. He has tried Silvadene in the past as well as intralesional inj ections and has remained symptom free for over a year and a half. He is current ly not on any medications nor is he allergic to any medications. He states that he has no actively draining lesions. He has never been in a tanning bed. He i s an occasional drinker and a nonsmoker. He is 18 years of age. The patient do es admit to a significant family history of hidradenitis suppurativa in the moth er and cousin and grandfather. He states he is not using currently any acne typ e washes or clindamycin topically. He states there is no pain to the areas. He is otherwise healthy and involvement is limited slowly to the buttocks. ASSESSMENT/PLAN: Folliculitis. Because he is a teenage boy, compliance is goin g to be key. I have broken the regimen down into one topical step and one pill to take daily in hopes that this will increase his chance of compliance. He is to do Acanya one pump and spread into a thin film in the buttocks area each day after shower. By mouth, he is to take one Doryx tablet once daily. I have writ ten him for a 90-day supply today. The side effects of doxycycline were discuss ed with the patient to include photosensitivity and stomach upset. The patient has been advised to wear sunscreen and physical blockers while exposing themselv es to the sun. They have also been informed that if they do in fact experience stomach upset, they may wish to try with a meal although a meal does not include dairy products such as milk, yogurts or cheeses. The patient has been informed that if they do experience intolerable gastrointestinal upset, nausea, vomiting or diarrhea, they are to discontinue the medication and call the office at once . The patient has been informed of the bleaching effects of benzoyl peroxide an d has been informed that one of the products prescribed today does contain this ingredient. They have been advised to use white towels or old towels when in co ntact with this product. They have been advised to let it dry completely before applying or removing clothing. We are going to follow up in 10 to 12 weeks to reassess and re-tailor treatment plan at that time if necessary. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_011_fox, raymond h._072512.doc 7/30/2012 8:39:30 PM 40960 1. Neoplasm, uncertain, likely keratoacanthoma type squamous cell carcinoma . Because of the frail nature of the patient and the wife's desire for a more i nvasive surgery, we have done a shave and electrodesiccation to the base. After obtaining written consent, the patient was prepped with alcohol. Buffered lido caine with epinephrine 1% was administered for local anesthesia. The lesion was biopsied by shave technique using a Dermablade. Drysol was used for hemostasis . Polysporin ointment was applied and the wound was bandaged. The patient tole rated the procedure without complaint, and wound care instructions were given. Pathology results will be mailed to the patient. Electrodesiccation was used fo r hemostasis and additional two rounds were done to the base. I discussed the i mportance of using a mild soap in the bath or shower such as Dove for sensitive skin, Oil of Olay, CeraVe or Cetaphil. We also talked about avoiding hot shower s or baths and applying a thick emollient cream within three minutes of exiting the bath or shower while the skin is still damp. The patient states he has used Lac-Hydrin before prescription strength, but always runs out and I have recomme nded AmLactin over-the-counter and I have given them samples and coupons today i n office.

2. History of squamous cell carcinoma. We discussed monthly skin checks, l ooking for any new or changing pigmented lesions. We also asked the patient to look for an irregular border, asymmetry, change in color or increase in diameter of any pigmented lesion. Given the fact that the patient has extensive sun dama ge and he is elderly and frail, we will see him in four weeks for a followup to ensure it is healing correctly. Wound care was discussed with the patient. He understands. If there is The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_012_calen, elizabeth e._072512.doc 7/30/2012 8:39:30 PM 4 0960 SUBJECTIVE: Elizabeth presents to the office today for a dry itchy raised place on the right ankle as well as a place on the right elbow. She states she has h ad treated via liquid nitrogen cryotherapy in the past, but states it is still t here. The plaque on the right ankle; the patient had been given an ointment at last date of service. She was told it was psoriasiform plaque and she uses twic e daily but the patient states that it had never receded or improved. Current m edications include Hyzaar, TriCor, vitamin D and Os-Cal. She is allergic to Cec lor. The patient does have a history of psoriasis. At this point, she states i t is a mild case and under good control at this time. She has never been in a t anning bed. She is a nondrinker and nonsmoker. 1. Neoplasm, uncertain. First one is in the right Achilles area. The diff erential needs to be rule out psoriasiform plaque versus verruca. After obtainin g written consent, the patient was prepped with alcohol. Buffered lidocaine wit h epinephrine 1% was administered for local anesthesia. The lesion was biopsied by shave technique using a Dermablade. Drysol was used for hemostasis. Polysp orin ointment was applied and the wound was bandaged. The patient tolerated the procedure without complaint, and wound care instructions were given. Pathology results will be mailed to the patient. 3. Psoriasis, looks to be under good control. She does have some xerosis p articularly on the palmar and plantar surfaces of both feet and hands. I am goi ng to give the patient 60 g tube of clobetasol, which I would like for her to tr y twice daily to these areas with one refill over the next two weeks and then fo llow back up with her. If the clobetasol did work well, then we might go down t o maintenance which is urea cream for the dryness on the feet. Side effects of the steroid were discussed with the patient to include telangiectasias, skin atr ophy and thinning of the skin/cigarette paper appearance. This is the one that is used for a long period of time. I have advised her that these side effects o ften occur when the high potency steroids and even mid or low potency steroids a re used on a consistent basis. The patient voiced understanding. Follow up in two weeks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_013_macro.doc 7/30/2012 8:39:30 PM 37888 Jill s steroid side effects macro: The patient was informed of the side effects o f steroids today to include skin thinning and/or cigarette paper like appearance to the skin, skin atrophy, and/or telangiectasias. This was reviewed in office with the patient and they voiced understanding. It is understood that the pati ent is only to apply the steroid to the affected areas, and only when symptomati c. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_014_lynn, cassandra a._072512.doc 7/30/2012 8:39:29 PM 40 960 ASSESSMENT/PLAN: Acne vulgaris with postinflammatory changes and milial cysts w ith truncal involvement. I have started the patient on a triple therapy regimen

to include Acanya used q.a.m. and Doryx 150 used daily with a 90-day supply wri tten today and Tazorac 0.05% gel to be applied to the face at night. Side effec ts of Tazorac (Retin-A) were discussed to include redness, dryness and irritatio n. The patient has been advised she is to start this on Monday and Friday, titr ating up to every other night use and then titrating up to nightly use as tolera ted. She is also to use a nighttime moisturizer after applying the Tazorac to h elp this dryness and irritation. Additional 20 minutes was spent going over in detail with the patient today. A detailed acne regimen for them to include dosa ge and administration instructions for the cleansers, moisturizers and prescript ions prescribed today. All patient concerns were addressed and patient question s answered. Side effects of the medications were also reviewed with the patient in office today. They voiced understanding. The patient was counseled on the etiology and course of treatment for acne. I have advised them to expect the ac ne to get worse before it gets better. They may expect a flare-up approximately three to four weeks into treatment and this is normal. I usually will see the patient back at two months and have advised compliance for eight consecutive wee ks before reevaluating. The patient voiced understanding of this today in offic e. The patient has been informed of the bleaching effects of benzoyl peroxide a nd has been informed that one of the products prescribed today does contain this ingredient. They have been advised to use white towels or old towels when in c ontact with this product. They have been advised to let it dry completely befor e applying or removing clothing. The side effects of doxycycline were discussed with the patient to include photosensitivity and stomach upset. The patient ha s been advised to wear sunscreen and physical blockers while exposing themselves to the sun. They have also been informed that if they do in fact experience st omach upset, they may wish to try with a meal although a meal does not include d airy products such as milk, yogurts or cheeses. The patient has been informed that if they do experience in tolerable gastrointestinal upset, nausea, vomiting or diarrhea, they are to disc ontinue the medication and call the office at once. Also the Cetaphil oil-free DermaControl foaming face wash and the Cetaphil Derma Control oil-free moisturizer with SPF 30 samples were given to the patient today along with coupon. She may purchase this over-the-counter. This is also part of the acne regimen. Follow up will be in two months. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_015_macro.doc 7/30/2012 8:39:29 PM 37888 Retin-A side effects macro: The side effects of topical retinoid therapy were d iscussed with the patient to include dryness, redness, plaquing and/or irritatio n. I have advised the patient to start on Monday and Friday for the first week. She is to use small pea-size amount to the face, titrating up to every other n ight use after a week or two and then titrating up to nightly use as tolerated. I have also advised the patient that if they are unable to tolerate nightly use , they may simply continue on with every other night use if they are able to tol erate such. I have also informed the patient that they may use acne oil-free mo isturizer on top of the Tazorac to help offset some of the side effects. Cetaphil macro: The Cetaphil DERMACONTROL oil-free line of cleansers and moistu rizers were suggested to the patient to include as part of their acne regimen in office today. Samples and coupons were given to the patient. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_016_adams, joyce_072512.doc 7/30/2012 8:39:29 PM 41984 1. Seborrheic keratosis, central back. Reassurance. The patient was infor med of the benign nature of these lesions and no treatment is necessary at this time. 2. Dermatitis, not otherwise specified. Looks to be spongiotic in origin, located on the scalp, also possibly some itching secondary to seborrhea behind t he ears and also possibly with extension down the back. The patient already has

a prescription filled for ketoconazole shampoo, which she states she was using once weekly. I have advised her to go up to three times a week for the next mon th or so; we will see if that does indeed help with the dryness and itchy feelin g on the back as well as the scalp. She will be using this as a scalp soaking s hampoo and body wash, leave on 5 minutes and then rinse. The patient states she is good on refills. For the more persistent patches of dermatitis on the scalp , I have written her for clobetasol 0.05% solution. She may also rub a drop of this under her fingertips and apply onto the right and left pinnae of the ear. She also may apply a drop to the each palmar surface of the hand once to twice d aily and rub in. 3. Skin tag. The patient was informed of the benign nature of these lesion s and no treatment is necessary at this time. General skin care regimen was dis cussed with the patient. I have encouraged her to avoid any fragrance products and to instead try All Free and Clear detergent, no fabric softener and then gen tle moisturizers such as Cetaphil RESTORADERM and/or CeraVe line of moisturizers and washes. The patient understands, followup would be on an open-ended basis. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_017_bland, gerald h._072512.doc 7/30/2012 8:39:28 PM 4198 4 OBJECTIVE: On exam, he is a well-developed, well-nourished, Fitzpatrick type 1 male, in no apparent distress. The patient is free and clear of any psoriatic p laques at today's visit with the exception of a few dime-sized erythematous plaq ues with scale on the scalp. He states that these are unable to be treated at t his time as he is getting treatment on the vertex scalp for actinic keratosis wi th the Virginia Clinical Research Group currently. On examination of the poster ior aspect of the right calf, he does have a well-healed, well-approximated woun d from ED&C treatment of the biopsy-proven squamous cell carcinoma. There is a slight crust today, but no induration or recurrence of tumors noted on today's v isit. Examination mainly concentrated on the trunk, he has some light-tan to me dium-brown warty waxy stuck-on appearing papules consistent with seborrheic kera tosis and a few ill-defined waxy erythematous plaques on the right temple as wel l as right ear consistent with actinic keratosis, approximately 15 of these are also present on the dorsum of forearms bilaterally, six on the left hand, five o n the right arm and four on the dorsum of the left arm. So it is total of 15 on the arms and four on the left eyebrow lateral aspect, two on the right ear. To tal number of actinic lesions treated in office today equals 21. 1. Psoriasis with great improvement after doing light therapy for greater t han 20 weeks. I have advised the patient should he elect to do this again for a ny psoriatic flare-ups in the winter, we are happy to restart him on a series of light treatments at that time. For now, he will continue on the clobetasol app lied to any resistant plaques twice daily as needed for flares until he decides to start light therapy again. 3. Actinic keratosis. Greater than 16 lesions were treated in the office t oday with liquid nitrogen and cryotherapy x2 cycles. Postprocedural care and ex pectations were discussed with the patient. He understands. Additionally, he d id have involvement on the vertex scalp with regards to the actinic keratosis. This is being treated currently by Virginia Clinical Research Actinic Keratosis Study and was not able to be treated today in office. 4. Seborrheic keratosis. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. Followup for Gerald w ill be in approximately three to six months as needed for actinic keratosis foll owup. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_018_eugene, chris p._072512.doc 7/30/2012 8:39:28 PM 2867

2 SUBJECTIVE: Chris presents to the office today for annual skin check. He is ha ving some scalp issues as well. He is currently on medications of Zocor daily. He is not allergic to any medications. His primary care doctor is Dr. _____. The patient denies any personal or family history of skin cancer, but does admit to blistering sun burns as a child and states tanning bed use approximately 10 times in his life. He is a one-beer-per-week drinker and a nonsmoker. 1. Mild case of folliculitis of the scalp. I have given the patient some C lobex spray 0.05% 125 mL bottle along with a co-pay coupon and a sample, he is t o apply this at night only as needed for itch/flare. I have given him one refil l as well. I am going to have him do doxycycline 100 mg tablets, take one table t p.o. b.i.d. for 14 days. I have written him for 28 with no refills. He has t olerated doxycycline at this dosage in the past for folliculitis and has respond ed well to it. 2. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 4. Seborrheic keratosis: The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_019_bailey, margaret w._072512.doc 7/30/2012 8:39:28 PM 2 5600 SUBJECTIVE: Margaret presents to the office today for her second of four Vivite peels. The patient has not used Retin-A in the last 48 hours. Medications rev iewed. Allergies reviewed. Nondrinker and nonsmoker. Never used a tanning bed . The patient does note increased tone to the skin even after just one peel. ASSESSMENT/PLAN: Glycolic acid peel by Vivite from my personal inventory. This was performed in office today by myself. The skin was first prepped with Vivit e prepping solution after the patient had washed her face. I then applied the V ivite glycolic acid gel on to the face where it was left for six minutes, at whi ch time it was neutralized with sterile water. Aveeno calming moisturizer was t hen applied with SPF of 30 to the patient s skin. Postprocedural care and expecta tions were discussed with the patient. Consent form on file. She tolerated the procedure well. The patient has been informed not to use Retin-A for 48 hours pre or post procedure. She voiced understanding. She currently has two peels l eft. I have advised them to be performed every three to four weeks. The patien t understands two days prior to scheduling the peel, she is to discontinue the r etinoids. Follow up in four weeks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_020_estep, june_072512.doc 7/30/2012 8:39:27 PM 26112 SUBJECTIVE: June presents to the office today for suture removal on the right u pper extremity in the elbow region and the flexor fold of the right upper extrem ity. The patient states no fevers, sweats or chills nor any abnormal oozing, bl eeding, crusting or drainage from the wound. OBJECTIVE: On examination today, it is a well-healing and well-approximated wou nd with just some mild postinflammatory erythema at the wound site as well as so me residual erythema from where the bandage was. This looks like an allergic co ntact reaction. The patient was evaluated by Dr. Rolfe prior to having the sutu res removed by myself. The patient presents for suture removal. Patient has no complaints about the su rgical site, and the wound has healed without any complication. The wound was c leansed and sutures were removed. The patient was instructed to call me if ther e is any concern about the surgical site in the future.

Dr. Rolfe has suggested a _____ liquid skin bandage cyanoacrylate spray be appli ed to the wound after suture removal. This was done. A thin coat was applied t o the area x3. The patient has been advised this will dry up to a striae and wr ap like texture and fall off. She is to favor the area that is located on a fle xor fold. Aftercare questions were answered with the patient and she will be fo llowing up in three months for a recheck on the elbow given her history of both squamous cell and melanoma type skin cancer. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_021_gaskins, charles_072512.doc 7/30/2012 8:39:27 PM 2764 8 SUBJECTIVE: Charles presents to the office today for a recurrent rash, which wa s treated at the last date of service of 11/02/2011 by Dr. Alan Rolfe. Prior he had had a three-week history of this aggressive hand dermatitis, which was trea ted successfully with clobetasol ointment by Dr. Rolfe for a period of three wee ks. Dr. Rolfe had advised him to stop use after two weeks and then cycle it out as needed for flares. The patient said that he was then told by a primary care provider that the clobetasol was too strong and should not be used on the chron ic basis. ASSESSMENT/PLAN: Acute dyshidrotic eczema of the hands with recent flare. The upper extremities are extremely dry and the flares are severe enough today that the patient was seen by Dr. Alan Rolfe in the office and he has advised a two-we ek taper of prednisone to be dosed as follows; prednisone 10 mg tablets take fiv e tablets p.o. days 1 through 3, tapering down to four tablets p.o. days 4 throu gh 6, tapering down to three tablets p.o. day 7 through 9, tapering down to two tablets p.o. days 10 through 12, tapering down to one tablet p.o. days 13 and 14 for a total of 42 with no refill. Additionally, he has been cleared to use the clobetasol with occlusion after work at least once daily, but twice daily was a dvised as needed for the thickened flared-up areas. If he does not get signific ant suppression of the inflammatory dermatitis, then we would like to see him ba ck for a followup. Patch testing was discussed as a possibility in the future a s well. At this point, it is open-ended. All the patient s questions were answer ed today and approximately 15 minutes was spent with the patient discussing the etiology, course and treatment for chronic hand dermatitis. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_022_ramsey, troy d._072512.doc 7/30/2012 8:39:27 PM 28160 SUBJECTIVE: Troy presents to the office today for a total body skin exam and so me injections on his psoriatic plaques. The patient states that these are only present on the left knee and the fingertips of the hands as well as the dorsum o f the fingers. Troy denies any personal or family history of skin cancer. He d oes admit to blistering sunburns as a child and does admit to tanning bed use. He is unsure how many times. He is a three-drinks-per-week drinker and a nonsmo ker. No medications. He is allergic to penicillin. 1. Plaque psoriasis, mild involvement. Largest patch is quarter sized on t he left patellar surface of the knee, also some involvement on the dorsum of the fingers as well as the dorsum of the knuckles of both hands bilaterally and inv olvement of two fingertips of the left hand and two fingertips of the right hand . Approximately 3 cc of Kenalog 4 mg per cc was injected into these lesions tod ay in a series of approximately 10 injections. This was done under aseptic tech nique. Postprocedural care and expectations were discussed with the patient. H e tolerated the procedure well. Dr. Rolfe has cleared this patient to have thes e localized injections, though he is going to have ankle surgery on the right an kle in approximately one week. 2. Tinea pedis, right foot. Naftin 2% cream was written for the patient. Copay coupon and samples given in the office today. He is to use this once dail

y apply to the affected area of the foot for two weeks. I have written him for one large pump. 3. Neoplasm, uncertain, rule out BCC versus ruptured hair follicle versus l ichenoid keratosis. Under aseptic technique and 1% lidocaine the lesion was rem oved with a DermaBlade technique. Electrodesiccation was applied to the base. A dry dressing with Polysporin was applied and wound care instructions were given . The proposed procedures, alternatives, risks and benefits were discussed with the patient. Follow up will be based on the pathological diagnosis and as neede d. The patient was informed that they will be made aware of the results in two to three weeks either by phone or via mail. If they do not hear from us in four weeks they are to call us. Here this was done in the office today by dermatolo gy technician, Kelly Walker. 4. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. Followup will be pending pathology result s; however, if all comes back as benign, then we will see him back in approximat ely one year for his next total skin exam or earlier should he desire for the in tralesional injections for his plaque type psoriasis. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_023_deaner, james_072512.doc 7/30/2012 8:39:26 PM 48640 SUBJECTIVE: James presents to the office today for a rash of concern, which the patient has been treated for with Silverex and acyclovir. He was initially see n by his primary care provider, Rose Hipol and she had believed it was shingles in nature, had treated it with a combination of Zovirax topical and also ten day s of acyclovir 800 mg taken five times daily. He states he is almost done with the acyclovir and states that his acyclovir combined with the Zovirax had cleare d this successfully. However, he also then developed a rash on the left arm, wh ich Dr. Hipol has now given him betamethasone valerate cream, apply twice daily. This has resulted in significant relief. However, he is in today to see if an y further diagnostic testing is warranted. He is allergic to Demerol. Other th an the acyclovir and the betamethasone valerate, the patient is taking naproxen, atenolol, aspirin, Micardis, HCT, and simvastatin. Surgical operation for righ t testicle removal. He also does have a past medical history of arthritis. He is a nondrinker and nonsmoker. 1. Dermatitis, not otherwise specified. The patient was seen by myself and Dr. Alan Rolfe today in office. He has advised Lidex cream to the area, which was a bit stronger than his current topical steroid. A potent topical steroid i s what is needed for the next four weeks to see if we can clear this up. Favor the differential diagnosis of lichen planus, but he cannot tell for sure without biopsy. 3. Xerosis. I discussed the importance of using a very mild soap in the ba th or shower such as Dove for sensitive skin, Oil of Olay, or Cetaphil. We also talked about the importance of moisturizing directly after the bath or shower, when the skin is still damp, with a thick emollient cream such as Cetaphil Cream or Vaseline Creamy Formula. The patient also points to an area on the lateral aspect of the right lower extremity. There is a hyperpigmented thickened papule , which dimples at one compression consistent with dermatofibroma. 4. Dermatofibroma, lateral aspect right leg. The patient was reassured of the benign nature of this condition--no treatment is necessary. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_024_champagne, terri l._072512.doc 7/30/2012 8:39:26 PM 4 8128 OBJECTIVE: On examination, she is a well-developed, well-nourished Caucasian fe

male, in no apparent distress. I did examine today the scalp, face, neck, trunk , and bilateral upper extremities. On examination of the face, she does have nu merous light- tan to light-brown macules of various shapes and sizes, one partic ularly large, one diamond nickel size in diameter, light brown on the face, all consistent with solar lentigines. There is a 6-cm well-circumscribed, pink fles hy papule on the central back consistent with benign intradermal nevi. The pati ent states that has remained stable and has not noticed any changes or any sympt oms such as spontaneous bleeding or any ulceration or problems with healing. Sh e does have on the back a large warty, waxy, stuck-on appearing papule, light br own in nature consistent with irritated seborrheic keratosis on the right bra li ne. She also does have in the inframammary region a couple of irritated light b rown warty, waxy, stuck-on appearing papules as well also consistent with seborr heic keratoses and some which are nonirritated, scattered around the trunk as we ll. 1. Solar lentigo. The patient has one particularly large one on the right zygoma region, which she would like to know what her options would be with regar ds to removal. I have discussed about bleaching creams and Retin A may give a v ery subtle lightening effect. Her best part would be to have it removed via las er. I have given her the information for Dr. Lawrence Chang to discuss IPL remo val of her solar lentigo on the right cheek. 2. Benign nevi. These are all well marginated, homogenously pigmented, sym metrical, benign appearing moles. We reviewed the ABCDs of melanoma, and a hand out detailing this information was given to the patient. The patient understand s that if any of these lesions begins to change, they are to return to clinic fo r re-evaluation. We discussed monthly skin checks, looking for any new or chang ing pigmented lesions. We also asked the patient to look for an irregular borde r, asymmetry, change in color or increase in diameter of any pigmented lesion. Today I reviewed sun protection guidelines. I discussed ABCD's and the use of su nscreen. I also recommended monthly self skin exam. The patient understands we s hould be notified for any changing lesions, new, or concerning lesions. I also d iscussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours. 3. Irritated seborrheic keratosis. Three were treated in office today, one on the back, two on the abdomen with liquid nitrogen cryotherapy as a courtesy to the patient. This was done in three cycles. Postprocedural care and expecta tions were discussed with the patient. She tolerated the procedure well. 4. Seborrheic keratosis. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. Given that she _____ and has a family history of skin cancer, I have recommended a followup annually. She is to start her baseline skin exam sometime this year as her schedule allo ws. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_025_cassidy, patrick_072512.doc 7/30/2012 8:39:36 PM 4147 2 SUBJECTIVE: Patrick presents to the office today for some reported hair loss he has had noticed after having an extremely stressful period in his life. His sp ouse recently passed away over the past year and he has had his adult children m ove in with him. These are his two sons. The patient states that it has been v ery stressful and has noticed thinning out of the hair especially in the frontal and vertex region. He states he also has an area on the vertex scalp, which wa s treated with cryotherapy last date of service, 06/28/2012 by physician assista nt, Lindsay Turner and states that it still is a thickened troublesome spot, whi ch he constantly picks at. He is wondering if it might be able to be re-frozen today. 1. Dermatitis, not otherwise specified with some mild dryness on the vertex scalp. I have given the patient some samples of OLUX-E Foam to use there as he does report it is somewhat itchy at times. One or two samples should be enough

to hold him for the next few weeks or so to determine if this is helpful. I ha ve also done a light refreeze to the lesion as he states that this has helped in the past. This was done with liquid nitrogen cryotherapy x3 cycles as a courte sy to the patient in the office today. Postprocedural care and expectations wer e discussed with the patient. He tolerated the procedure well. 2. Alopecia, likely age related, but may also have a component of telogen e ffluvium given history of stressors over the last year to include wife s death and older children moving in with him. I have suggested the patient to try the Rog aine Foam over-the- counter. I have given him the patient education sheet for R ogaine as well as the website, which he may go on to view the frequently asked q uestions as well as learn dosage and administration. Followup is going to be in August 2012. He states this is already scheduled with PA Lindsey Turner. Foll owup will be at that time unless of course he needs us sooner. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_026_dixon, kinja j._072512.doc 7/30/2012 8:39:25 PM 40960 SUBJECTIVE: Kinja presents to the office today for unusual bumps on the face. He has been on clindamycin, Epiduo, and Tazorac in the past. Tazorac for his ac ne keloidalis nuchae, Epiduo and clindamycin for his acne on the face. He state s that it has done well; however, he has gotten a few persistent inflammatory pu stules on the face of late and he states he does pick at them and this results i n a darkened, thickened area, which he is extremely dissatisfied with regards to cosmesis. The patient is not taking any other medications. States no allergie s to any medications currently. He has never been on a tanning bed. He is a no ndrinker and nonsmoker. ASSESSMENT/PLAN: Acne vulgaris with some acneiform folliculitis present today a nd some postinflammatory changes from older resolving lesions. Since I do not l ike to inject acneiform lesions on Fitzpatrick type 5 skin due to the risk of hy popigmentation, I have advised a course of Doryx 150 mg tablets. He is to take one tab q.d. for the next two months in addition to his Epiduo and clindamycin s olution, refills of which were given in the office today for the patient. Also I refilled this Tazorac as he states that is doing a good job of clearing the ac ne keloidalis nuchae on examination today and no active pustules or papules are present on the base of the neck and is responding nicely to the Tazorac topical therapy. With regards to the inflammatory pustule on the right cheek, courtesy extraction was done today in the office by dermatology technician _____, under a septic technique with a sterile comedone extractor. Postprocedural care and exp ectations were discussed with the patient. He tolerated this procedure well. F ollow up in two months. The patient does not like to take oral medications and is interested in doing just solely a two-month trial and discontinuing at that t ime. I have told the patient that this is fine and we will revisit when we meet in two months. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\120725_027_kliewer, heidi n._072512.doc 7/30/2012 8:39:25 PM 476 16 1. Benign nevi. All nevi are well marginated, homogenously pigmented, symm etrical, benign-appearing moles. We reviewed ABCDs of melanoma. The patient wi ll monitor moles for any change or growth. The patient understands if any of th ese lesions begin to change, they are to return to clinic for re-evaluation. 3. Xerosis of the heels. I have given the patient a script for urea 40% cr eam. She may apply this once or twice daily avoiding the toenail beds for help with dryness over the next two weeks. I have advised the patient that if she do es not tend to get pregnant in the next year or two, which she states she may, s he is to discontinue the Retin A as well as the urea cream, but that she can com e in for some class B, some products that are safe for acne and are class B in p

regnancy such as clindamycin and Finacea. I have advised annual yearly skin che ck as the patient does have variation in the color of her moles as well as a fam ily history of skin cancer both of her father and brother. We will see her back for her next skin exam in one year unless of course she needs us sooner. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\qcd-cbe\dictation ends abruptly\120725_001_lilly, alex_072512.doc 7/30/2012 8:39:34 PM 36864 OBJECTIVE: The patient is a well-developed and well-nourished Caucasian male in no apparent distress accompanied by his mother today. On the dorsum of the rig ht hand, he does have a verrucous plaque still present in a half doughnut shaped ring. There is hyperpigmentation center from other procedures that have been d one to the wart. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\samples\120723_001_lorenz, eileen j._072312.doc 7/27/2012 10:18:38 PM 39 424 SUBJECTIVE: Ms. Lorenz presents to the office today for total skin exam. The p atient denies any personal or family history of skin cancer. She does admit to tanning bed use over 20 times in her lifetime. She does also admit to blisterin g sunburns as a child. 1. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 3. Benign nevi. All nevi are well marginated, homogenously pigmented, symm etrical, benign-appearing moles. We reviewed ABCDs of melanoma. The patient wi ll monitor moles for any change or growth. The patient understands if any of th ese lesions begin to change, they are to return to clinic for re-evaluation. We discussed monthly skin checks, looking for any new or changing pigmented lesion s. We also asked the patient to look for an irregular border, asymmetry, change in color or increase in diameter of any pigmented lesion. Today, I reviewed su n protection guidelines. I discussed ABCD s and the use of sunscreen. I also rec ommended monthly self skin exam. The patient understands we should be notified for any changing lesions, new, or concerning lesions. I also discussed the use of wearing a hat and avoiding outdoor sun exposure at the peak sun hours. Follo w up will be in one-year for her next total skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\samples\120723_002_brock jr., allen p._072312.doc 7/27/2012 10:18:36 PM 37376 SUBJECTIVE: Mr. Brock presents to the office today for some bumps that his barb er had notice on the scalp as well as excessively dry total skin on the right th umb distal tip. He says that bothers him in appearance. He noticed no other sk in problems and states that they really do not itch. They are not symptomatic, but the barber when he had cut his hair rather short had notice that he had some inflammatory red papules located in the scalp region. He states that these are not present in the beard. The patient is not allergic to any medications. He is not on any daily medications. He does give a past history of seasonal allerg ies and is a nondrinker and nonsmoker. 1. Folliculitis of the scalp looks to be resolving in nature, nonsymptomati c to patient. I will do a 10-day course of Doryx 150 mg tablets for the patient to take one tab p.o. q.d. Side effects of doxycycline therapy to include photo sensitivity and GI upset were discussed with the patient. He understands if he

experiences this, he is to discontinue medication and call the office at once. Co-pay coupon was given today along with instructions and how to activate for th e patient. He understands and will call the office if there are any issues with regards to cost. 2. Dermatitis, not otherwise specified with xerosis right thumb distal tip, favor diagnosis of dyshidrotic eczema. This does not look to have any type of fungal qualities to it. I am going to give the patient triamcinolone 0.1% ointm ent 30 gram tube to apply twice daily. I have advised the patient if neither co ndition has improved over the next two weeks we would like to see him back, othe rwise follow up will be open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\samples\120723_003_deberry williams, lynette w._072312.doc 7/27/2012 10:18 :36 PM 41984 OBJECTIVE: On exam, she is a well-developed, well-nourished African-American fe male, in no apparent distress. I did examine today the scalp, face, neck, trunk , and bilateral upper extremities at today s visit as well as the lower extremitie s bilaterally. On examination of the scalp, it is free and clear of any scale o r fine flaking. Face appears clear as well. The Promiseb and ciclopirox therap y for the seborrheic dermatitis are doing excellent job of controlling her sebor rheic dermatitis flares. Also, no inflammatory papules or pustules are seen tod ay on the face, except for a few areas of postinflammatory hyperpigmentation fro m older resolving lesions. On examination of the leg, she does have some postin flammatory hyperpigmentation as well from older resolving folliculitis. I have advised the patient that this may last for a period of weeks to months, but that does not look infectious at this point. The doxycycline that she had taken pre viously for this has done an excellent job of clearing up the folliculitis. 1. Dermatitis, not otherwise specified, likely allergic contact dermatitis reaction, secondary to nickel and/or other ingredients. The patient states she has used a new deodorant over the past week and attributes that to the axillary vault rash. I have advised her to go back to her regular deodorant where no jew elry in the interim and finish out her remaining five days of prednisone as we w ill need to have her wait at least two weeks before starting the patch test. Th e patient is scheduled to come in on August 13th for a patch test placement with acute read on 08/15/12 and delayed read on 08/17/12. I have advised the patien t on 08/17/12 will be the day where the treatment plan is tailored to whatever s he may or may not be reacting to it. We have discussed that there is nothing ad ditional I would do other than to encourage her to stay on the 24-hour systemic antihistamine therapy and finish out her five days of prednisone. The next step clearly is patch testing. 2. Acne vulgaris, doing excellent with clindamycin topically and Atralin ge l q.h.s. along with over-the-counter cleansers. Refills were written for all to day both clindamycin and Atralin. She is good to go on refills for the next six months or so and she may call in for up to a year s worth without having to come in for co-pay if the patient so desires. 3. Seborrheic dermatitis, doing well with Promiseb for the face and ciclopi rox shampoo. Refills were written for these as well up to six-month supply. Sh e may opt to do a year s worth of refills over the phone and is authorized for tha t if the patient so desires. Follow up will be on August 13th for a patch test placement. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\samples\120723_004_hamilton, katherine l._072312.doc 7/27/2012 10:18:35 PM 39936 SOCIAL HISTORY: She gives no personal history of skin cancer. She does state t hat her maternal grandmother had a cousin who did have some type of skin cancer,

she is unsure of which type. She does have used a tanning bed approximately on e month out of her entire life. Concerns today include acne. She states she di scontinued the tretinoin and instead has gone to an Apricot scrub, she uses in t he morning. She uses an Aveeno SPF 15 daily moisturizer and continues to use th e CeraVe p.m. She states this maintains good control of her acne. She does not ice some blackheads in the armpits. She states she does try to pick at these. She does wax her armpits. She is wondering if there is any topical she might be able to try to help with improvement of this problem. Also, the patient states she had a rash on the hands and feet as well as having some systemic symptoms a couple of months ago. She states that they turned into red bumps and then star ted stages of desquamation, which she is still having some dryness issues. The patient s provider stated that was likely hand-foot-and-mouth disease and had trea ted it symptomatically as it is viral. The patient is wondering if the continue d desquamation is normal. 1. Xerosis of the hands and feet. A very minimal amount of desquamation is still present. It looks to be in the final stages of resolution. I have recom mended good emollient moisturization and if necessary some over-the-counter hydr ocortisone ointment can be applied twice daily as needed for symptomatic itching . I discussed the importance of using a very mild soap in the bath or shower su ch as Dove for sensitive skin, Cetaphil, or CeraVe. Showers should be with warm or cool water and limited to 5 to 10 minutes. After towel drying, the patient should apply a thick emollient cream when the skin is still damp. Cetaphil, Cre amy Vaseline, Eucerin, and CeraVe are good moisturizers to use. Another applica tion of moisturizer should be used during the day. 2. Benign nevi. All nevi are well marginated, homogenously pigmented, symm etrical, benign-appearing moles. We reviewed ABCDs of melanoma. The patient wi ll monitor moles for any change or growth. The patient understands if any of th ese lesions begin to change, they are to return to clinic for re-evaluation. 3. Acne vulgaris. Face under good control with the acne scrub and facial m oisturizers as needed. For the armpits, I have recommended benzoyl peroxide was h such as PanOxyl wash with the clindamycin 1% lotion topically to be applied af ter the shower. Side effects of the medications were discussed with the patient in office today. She understands. Coupon for PanOxyl over-the-counter was giv en to the patient today in office. We will see her back in one year for her nex t total skin exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\samples\120723_005_simpson, charity p._072312.doc 7/27/2012 10:18:34 PM 37888 1. Acne vulgaris with postinflammatory changes and textural scarring. The patient has been informed that this is her third Accutane start and if she has l ost to follow up at this point, we will not be resuming Accutane therapy again f or the patient. 2. Urine pregnancy for patient was done in office today by dermatology tech nician, Tabby Starkey showing negative. Additionally, I have given her labs to obtain serum hCG, fasting lipid panel, CBC, and CMP, which she will have perform ed at Sentara Norfolk Labs on Thursday prior to her four-week followup on Monday . Once labs have comeback and that the patient is seen in four weeks, I will go ahead and write her for Accutane 40 mg tablet one tab once daily for two weeks titrating up to one tab by mouth twice daily for two weeks for the initial first month s dose. I have advised the patient, she is going to need to do her best to remain compliant since this is going to be the third and final opportunity she has with this provider to make this happen. The patient voiced understanding. Follow up in four weeks. 3. With regards to the hyperhidrosis, the patient states that at this time it is not severe, but that it often times does get severe in certain situations. I advised the patient to try to be compliant on the Accutane and to see how mu ch improvement she can get on all of her sweating. At that point, if she comple

tes six months of Accutane therapy and still sweating, we can discuss systemic t reatment such as Robinul therapy at that time. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\samples\120723_006_brisbin, ruth a._072312.doc 7/27/2012 10:18:33 PM 394 24 ASSESSMENT/PLAN: Dermatitis, not otherwise specified, consistent with granuloma annulare. The patient reports good response to clobetasol, but states she has not been using as of late because she was unsure how long of holiday to take for the medication. I have advised the patient that she may use it twice daily for a period of two weeks and if the areas have resolved to include the plaque-like appearance, flattening, and the erythema residing, the patient is then to stop the medication and to take a holiday until the next time she become symptomatic again. The patient finds she is unable to take a holiday for any significant am ount of time. I would like to see her back for further diagnostic testing. I d id inject intralesionally to test plaques to see if she can get any fasting resu lts, one was injected on the medial aspect of the right chin and two injection p oints approximately 0.3 cc of Kenalog 4 mg/cc was injected into this plaque unde r aseptic technique. The patient tolerated the procedure well. One plaque was also injected on the left proximal lower extremity a quarter-size plaque in natu re. Four injection points were made and approximately 0.7 cc of Kenalog 4 mg/cc was used. This was also been under aseptic technique. The patient tolerated t he procedure well. Postprocedural care and expectations were discussed with the patient. She under stands. I have also written her for another two-week clobetasol and would like for her to resume use of this twice daily as needed for flares. Taking holidays as discussed above. Follow up will remain open ended; however, the patient has requested a total skin exam, I have advised her let us do this in the next mont h or two. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\samples\120723_007_lee, dorothy l._072312.doc 7/27/2012 10:18:35 PM 4198 4 SUBJECTIVE: Ms. Lee presents to the office today for a nail on her right ring f inger as well as her right great toenail, which she states are bothering her wit h regards to tenderness. She also has a bump near the right medial canthus and states that she continues to itch all over. Of note, the patient has been seen in the past multiple times for generalized itching. It has been going on for th e last few years. This is unexplained by any rashes or medical conditions. She has currently used triamcinolone in the past as well as Atarax. She states tha t one Atarax taken every 4-6 hours does not do much to quell the itching. The p atient was unaware she was able to do two hydroxyzine every 4-6 hours as needed for itch. 1. Milia cyst, right eye. Extraction was done today in office by dermatolo gy technician, Tabby Starkey. Under aseptic technique, a 20 gauge needle was us ed to roof the top epidermal layer of the skin. A comedonal extractor was then used to apply pressure to the calcified papule and it was extracted in office to day. Postprocedural care and expectations were discussed with the patient, she understands. 2. Xerosis of the scalp. The patient was seen by both myself and Dr. David M. Pariser in office today. Due to the dyspigmentation and flaking, she has ad vised Clobetasol solution to be applied to the scalp at night, rinsing off in th e morning as needed for itch/flare. Also, she has advised increasing the dose o f hydroxyzine from 25 mg p.o. q.4-6h. to 50 mg p.o. q.4-6h. 3. Paronychia, right ring finger and right great toenail. Dr. David has to ld the patient that he recommends a Lotrisone 0.1% lotion to be massaged into th

e bed twice daily, especially after wet e continues to experience toe pain that further treatment. The patient voiced The patient understands and accepts the ted with the treatment.

work. He has advised Ms. Lee that if sh she may need to consult a podiatrist for understanding. Followup is open-ended. risks, benefits and alternatives associa

e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\samples\120723_008_pierce, lance_072312.doc 7/27/2012 10:18:32 PM 37376 ASSESSMENT/PLAN: Acne keloidalis nuchae with hyperpigmentation. I have discuss ed with the patient in office the course and treatment for this skin condition. I have advised him that a laser hair removal would be effective. Lasers are no t indicated especially in Fitzpatrick type 5/6 skin coloring at this point. We are going to try and do this treat topically and do a 90 course of doxycycline. Regimen as follows, PanOxyl wash to the area once or twice daily, then he will apply in the morning a thin film of clindamycin 1% lotion, which I have written for him in the office today and let dry. Side effects of benzoyl peroxide to in clude bleaching were discussed with the patient and wife. They have both voiced understanding. A coupon for PanOxyl wash was given to the patient, he may get this over-the-counter and use in conjunction with the clindamycin topically. Fo r the oral treatment, he will do a doxycycline capsule one tab p.o. b.i.d. for a course of 90 days. Side effects of doxycycline therapy were discussed with the patient to include sun sensitivity and GI upset. The patient understands that he may take this with the meal if he is somewhat creasy, although it is unadvise d to take with any kind of dairy products. Both patient and wife voiced underst anding. Explicit instructions were written for the patient in office today and approximately 20 minutes was spent in office discussing the regimen, going over side effects, and the patient s questions and concerns. We will be following up i n approximately two months to see how he is doing on the doxycycline therapy. I have advised the patient if we are not 75% improved at that time, we may wish t o add on other treatment regimen such as intralesional injection. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\samples\120723_009_nelson, nicole k._072312.doc 7/27/2012 10:18:31 PM 53 760 SUBJECTIVE: Nicole presents to the office today for a wart, which she states ha s been on her forehead recently as well as one on the left knee. She also has a mole of suspicion that is tiny, yet it is very painful when touched on the left arm. The patient has a history of having moles removed in the past, none of th em were atypical. She gives no personal or family history of skin cancer and ad mits to tanning bed use less than 20 times in her life. While she does not admi t to blistering sunburns as a child, she does give a history of life guarding as a youth. She is currently not on any medications nor is she allergic to any me dications. She is an occasional drinker and nonsmoker. OBJECTIVE: On exam, she is a well-developed, well-nourished Caucasian female, i n no apparent distress. On examination of the forehead, she does have a 4-mm hy perkeratotic papule with some filiform extensions consistent with filiform verru ca on the left forehead. She also does have one verrucous papule present on exa mination of the left knee suprapatellar aspect. On the left arm, there is a 2-m m light-brown, well-circumscribed, evenly pigmented macule, which well it looks to be consistent with lentiginous junctional nevus cannot rule out atypical nevi with recent history of it being very painful. She also has one present on the left abdomen, this is 3 mm medium brown, well-circumscribed, and evenly pigmente d. The patient states no history of pain and that it just catches on various cl othing and this looks to be consistent with the benign compound nevi. 1. Verruca, one on the left forehead and one on the left knee were treated in the office today, both with liquid nitrogen cryotherapy x3 cycles. Postproce dural care and expectations were discussed with the patient. She tolerated the procedure well.

2. Neoplasm uncertain, left arm, rule out atypical nevus versus dysplastic nevus versus lentiginous junctional nevus, recent onset of pain. After obtainin g written consent, the patient was prepped with alcohol. Buffered lidocaine with epinephrine 1% was administered for local anesthesia. The specimen was obtaine d with a 2mm punch biopsy. 4-0 nylon suture was placed. Drysol was used for he mostasis. Suture was not used for closure rather Surgifoam closure was done in the office today with a pressure dressing. The patient tolerated the procedure well. Wound care was discussed with the patient. She voiced understanding. Pa thology results will be mailed to the patient. This was done in the office toda y by dermatology technician, Tabby Sturkey. 4. Benign nevi. All nevi are well marginated, homogenously pigmented, symm etrical, benign appearing moles. We reviewed ABCDs of melanoma. The patient wi ll monitor moles for any change or growth. The patient understands if any of th ese lesions begin to change, they are to return to clinic for re-evaluation. We discussed monthly skin checks, looking for any new or changing pigmented lesion s. We also asked the patient to look for an irregular border, asymmetry, change in color or increase in diameter of any pigmented lesion. Today I reviewed sun protection guidelines. I discussed ABCD s and the use of sunscreen. I also recomm ended monthly self skin exam. The patient understands we should be notified for any changing lesions, new, or concerning lesions. I also discussed the use of we aring a hat and avoiding outdoor sun exposure at the peak sun hours. The import ance of daily sun protection was discussed. The patient was given an informatio nal brochure on skin cancer and a starter sample of a complete sun block. We wi ll follow up with the patient in one year for total skin exam unless of course p athology dictates that we see her sooner. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\samples\120723_010_thumm, linwood a._072312.doc 7/27/2012 10:18:30 PM 50 688 1. Neoplasm uncertain, pinna of the right ear, rule out BCC versus SCC vers us CDH. After obtaining a written consent, the patient was prepped with alcohol . Buffered lidocaine with epinephrine 1% was administered for local anesthesia. The lesion was biopsied via a shave technique using a Dermablade. Drysol was used for hemostasis. Polysporin ointment was applied to the wound and covered w ith a bandage. Wound care was reviewed. The patient tolerated the procedure we ll. Pathology results will be mailed to the patient. This was done in the offi ce today by dermatology technician Tabby Sturkey. Wound care was discussed with both the patient and wife. They tolerated the procedure well. 2. Lentigo. The patient was reassured regarding the benign nature of these lesions. These lesions do, however, indicate diffuse sun damage. We discussed the importance of wearing a broad-spectrum sunscreen with an SPF 30 or greater whenever they are exposed to the sun. 3. Seborrhoic keratosis. The patient was informed of the benign nature of these lesions and no treatment is necessary at this time. Follow up will be pen ding pathology results. I have advised the patient if this does come back as ca ncerous in nature, he will most likely be following up with Dr. Chang for next c onsult, at which time he will be returned back to me for six-month upper body sk in exam. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\samples\120723_011_cowell, jewel r._072312.doc 7/27/2012 10:18:29 PM 537 60 SUBJECTIVE: Ms. Jewel presents to the office today for a few areas of concern. The patient has a past medical history of fibromyalgia, diverticulosis, allergi es, gastroesophageal reflux disease, and is having some menopausal symptoms. He r concerns begin with some itchiness and flaking on the face, but she states is

mainly in the brow and parinasal region. The patient does drink alcohol. The p atient does use tobacco also. OBJECTIVE: On examination today, she does have some fine flaking in this area, which looks to be consistent with seborrheic dermatitis. After examining the sc alp, face, and neck, I then examined the upper body to include the upper extremi ties bilaterally as well as the axillary vaults and palms, and dorsum of the han ds, fingers, and fingernails. On the right axillary vault, she does have a few areas of absence of pigment consistent with vitiligo. The patient then points t o her hands and feet. On the palmar surface bilaterally of the hands and the pl antar surface bilaterally of the feet, she does have some very mild xerosis pres ent. The patient states this has only occurred over the last month in earnest. She does give a history of dry skin since she can remember and does give a fami ly history of eczema as well. This does look indeed to be dyshidrotic in nature . There are some small vesiculations dry in nature present on the sides of the fingers as well as the toes, which leads me to believe this is likely dyshidroti c versus fungal, though no fungal culture has been done as of yet. 1. Seborrheic dermatitis. I have given the patient a prescription for keto conazole cream to be used by pea-sized amount to face and spread into thin film q.a.m. At night, she will do desonide lotion small pea-sized amount to face and spread into thin film in the p.m. For her vitiligo on the right axillary vault , I have given her samples of Protopic 0.01%, which she may apply twice daily. I have advised the patient this may be somewhat tingly on the first few applicat ions, she understands. I have advised the patient with regards to vitiligo, tho ugh this is an autoimmune process and the Protopic therapy may not help at all t o repayment; however, and something that I would like to try. Protopic is not c overed by insurance; therefore samples were given in the office today, which sho uld last over the next four to six weeks. 2. Dermatitis, not otherwise specified, favor the diagnosis of dyshidrotic eczema with generalized xerosis of the hands and feet. The patient was using mo metasone and states that she got a favorable response to this. On examination t oday, she looks great and I advised only some moisturization such as Cetaphil, R estoraDERM, and/or Vaseline petroleum jelly. Thus when she does get flares, I h ave written her for something slightly stronger than the mometasone, which is a 60-gram tube of Topicort 0.25% ointment. Again this is only twice daily, only a s needed, and only when symptomatic. The patient voiced understanding. Also a DTM was done to the left foot for comp leteness to rule out fungal. We will be following up with the patient in approx imately four to six weeks. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\samples\120723_012_joseph, francine e._072312.doc 7/27/2012 10:18:29 PM 47616 Francine presents to the office today for a patch test placement. She has had a biopsy done and was seen at suture removal on date of service 07/03/12 by PA, M elissa Alcox. Results of which showed an urticarial dermatitis. Patch testing was reviewed with the patient in the office today and a T.R.U.E test pamphlet wa s given to her. Patch test placement was administered today by dermatology assi stant, Nicole Martin. Follow up in 48 hours for acute read at the Carlton Offic e per the patient. She states she is also wanting the 96-hour delayed read and _____ treatment plan done at the Carlton office as well. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\samples\120723_013_smithson, bianca n._072312.doc 7/27/2012 10:18:28 PM 48128 ASSESSMENT/PLAN: PPD placement in the office today. Under aseptic technique, 0 .1 mL of PPD was placed into the left volar forearm. The patient tolerated the

procedure well. Postprocedural care and expectations were discussed with the pa tient, she understands. She will be following up in 48 hours for the PPD read. Treatment plan will be tailored at that time. Follow up in 48 hours. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\samples\120723_014_ferguson, james_072312.doc 7/27/2012 10:18:28 PM 5120 0 SUBJECTIVE: Mr. Ferguson presents today as an emergently seen fit-in for a rash on the face. The patient gives a history of pseudofolliculitis barbae as well as seborrheic dermatitis treated in the past with numerous topicals to include k etoconazole and desonide. He has also had a history of intertrigo as well. OBJECTIVE: One exam, he is a well-developed, well-nourished, alert African Amer ican male, in no acute distress. He does have a few inflammatory papules noted on the beard area along with some postinflammatory hyperpigmentation, which look s to be consistent with the pseudofolliculitis barbae. He has recently had a sh ave. When the patient was asked for his cleansing and moisturizing regimen, he states that he uses simply warm water, no soap, and then baby oil for moisturiza tion. He does have some fine flaking in the peribrow and parinasal regions cons istent with seborrheic dermatitis. ASSESSMENT/PLAN: Seborrheic dermatitis, peribrow and parinasal region. The pat ient is going to resume ketoconazole therapy twice daily for two weeks. I have written him for a large tube with few refills. If he is responsive to this, the n we will consider having him continue to use this as maintenance for his seborr heic dermatitis. He will also be using over the next two weeks Elidel 1% cream, I have given him samples today in the office and a script for a 60-gram tube wi th a couple of refills. I have advised the patient this is unlikely covered on his insurance plan, but the patient states he insists that it is. I have given him samples just in case. For the pseudofolliculitis barbae with hyperpigmentat ion and xerosis, I have advised that the patient discontinue the baby oil and th e close shaves and try to attempt to let the hair grow out somewhat. For the bu rning and itching, I would like for the patient to do 24-hour antihistamine ther apy consisting of fexofenadine 180 mg tablet to be taken during the day for nondrowsy daytime itch, do no take with orange juice and at night. I have written him for Atarax 25 mg tabs, he may take one to two at night p.o. p.r.n. itch, I h ave written him for 30 with a couple of refills. I would like to see him back i n approximately one week. If he is not improved at that time, we will re-tailor treatment plan as needed. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\samples\120723_016_crittenden, quimar c._072312.doc 7/27/2012 10:18:27 PM 50688 SUBJECTIVE: Quimar presents to the office today for six-week followup of DTM-pr oven tinea capitis on the scalp. The patient is on eight-week course of griseof ulvin, tolerating it well. The patient s mother states that the lymphadenopathy p resent in the occipital region has gone down significantly and she states the sc alp has cleared up nicely. Both Quimar s mother and brother have history of skin problems. He has no known drug allergies that the mother knows of. ASSESSMENT/PLAN: DTM-proven tinea capitis, treated with eight-week course of gr iseofulvin; he is currently on week-six. I have advised the patient we would be following up in two weeks to do a final re-culture. Because the patient has se en a mid-level over the last two visits, I have recommended followup with a staf f physician for the third visit. The patient s mother is to continue on applying the ketoconazole shampoo two to three times weekly to Quimar s scalp. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment.

e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\samples\120723_017_crittenden, quiaire d._072312.doc 7/27/2012 10:18:26 P M 51200 SUBJECTIVE: Mr. Crittenden presents to the office today accompanied by his moth er for followup of his atopic dermatitis and overall dryness. The patient s mothe r states she is using the Dove for sensitive skin and emollient to moisture and states that she is doing this once to twice a day especially after bathing. She states that he still has some itchy dry patches, which she has been putting on triamcinolone cream when she has had for her previous prescription at first. Sh e states the desonide simply do not keep him from itching. He has also been on pediatric anti-itch soaps in the past, but the patient s mother states that he doe s not lose any sleep at night from the itching. ASSESSMENT/PLAN: Atopic dermatitis with xerosis and postinflammatory changes. I have written the patient for a large tub of triamcinolone 0.1% cream. The pat ient s mother is to apply this only when needed for itch/flares. Side effects of topical steroids were discussed with the patient s mother. She voiced understandi ng. Additionally, he may opt to do the pediatric anti-itch soap at night as nee ded for itch, but the patient s mother states that the itch does not bother him at night. If it does, he may do Children s Benadryl as directed on bottle. Also go od moisturization was discussed. I have recommended Vaseline petroleum jelly ag ain, which she may get the dollar store. I discussed the importance of using a very mild soap in the bath or shower such as Dove for sensitive skin, Cetaphil, or CeraVe. Showers should be with warm or cool water and limited to 5 to 10 min utes. After towel drying, the patient should apply a thick emollient cream when the skin is still damp. Cetaphil, Creamy Vaseline, Eucerin, and CeraVe are goo d moisturizers to use. Another application of moisturizer should be used during the day. Continue to refrain from products containing fragrance. Followup ope n-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\samples\120723_018_srivastavaya, kavita_072312.doc 7/27/2012 10:18:25 PM 51712 SUBJECTIVE: Kavita presents to the office today for ongoing rash that she has h ad over the last few weeks treated per the past three weeks by her primary care provider with various oral and topical therapies to include Bactrim back on 07/0 5/12 for a course of 10 days. She is most recently on Augmentin 875/125 mg one tab p.o. q 12 hours over the last few days. She is written for seven-day course to take with food. She is also using topically clotrimazole and has used in th e past Neosporin. The patient states that the right thumb has complete loss of cuticle and she is also having a lot of abrading to the area especially when was hing. The patient denies any past history or family history of eczema. She is not allergic to any medications nor is she taking any daily medications exclusiv e of the current course of antibiotics. She is a nondrinker and nonsmoker. She has never used a tanning bed. ASSESSMENT/PLAN: Dermatitis, not otherwise specified, with chronic paronychia ( nail disease). The patient has been seen by both, myself and Dr. Robert J. Pari ser, in the office today. He has advised a high-potency steroid to be applied t wice daily over the next couple of weeks. As this looks to be mainly inflammato ry in nature and not infectious, we are going to discontinue the Augmentin as th e patient states she feels it has gotten worse with use of the Augmentin and we will discontinue on with high-potency topicals. Administration and dosage was d iscussed with the patient. She voiced understanding. We will follow up in two weeks to reassess and re-tailor her treatment plan at that time. However, I hav e advised the patient if she is not improving by weekend, she is to call the off ice and come in at once. She would be also applying this to the left hand in th e second/third interdigital space. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment.

e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\samples\120723_019_arnett, scott r._072312.doc 7/27/2012 10:18:23 PM 506 88 SUBJECTIVE: Scott presents to the office today for a mole of concern on the lef t cheek. The patient states he has had many people remark on the dark brown to black 1.5-mm lesion on the left cheek, which he has had over the last nine month s. On examination, it has grown from 1 to almost 2 mm in size. The patient is in today with concerns of skin cancer as both the mother and father have a histo ry of skin cancer. He is unsure of melanoma or non-melanoma type. The patient admits to blistering and sunburns. No tanning bed use, but he has been in Ohio over the last six years and states that with his Fitzpatrick type 1 skin, he has received many burns. ASSESSMENT/PLAN: Neoplasm uncertain, left cheek, rule out AN versus DN versus M M, family history of skin cancer and the mole has grown since the last visit of date of service 01/04/12. After obtaining written consent, the patient was prep ped with alcohol. Buffered Lidocaine with epinephrine 1% was administered for lo cal anesthesia. The specimen was obtained with a 2 mm punch biopsy. One stitch was placed with 5-0 nylon on the area of the left cheek. Drysol was used for h emostasis. Polysporin ointment was applied and the wound was bandaged. Wound c are instructions were reviewed. The patient tolerated the procedure well. Path ology results will be mailed to the patient. Followup will be for suture remova l in 5-7 days. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment. e:\medical transcription\pariser dermatology\samples\patricia jill lisinski, pac\samples\120723_023_smith, dante a._072312.doc 7/27/2012 10:18:21 PM 4044 8 SUBJECTIVE: Dante presents to the office today, accompanied by his father for a growth on the anterior tibial surface of the left lower extremity, which has bo thered him in appearance over the last 1-1/2 months. The patient gives personal and family history of eczema and is being currently treated with triamcinolone cream to the area. The patient s father states he is getting the triamcinolone cr eam on once or twice a day daily usually after baths. He has a history of sensi tive skin and also takes loratadine for his allergies. Dr. Robert J. Pariser has examined this patient in office with me today. He agr ees with assessment. For treatment plan, we will do liquid nitrogen and cryothe rapy. This was done three short cycles to the area today. Postprocedural care and expectations were discussed with the patient s father as well as the patient h imself. Dante tolerated the procedure well. I have advised the father, he is g oing to need to start him more treatment therapy and this can take anywhere from 3-6 months for the wart to completely resolve and I have advised the patient an d father this maybe a slow going process. Both patient and father voiced unders tanding. Home wart treatment sheet was given to the patient in office today. W e discussed treating the warts by soaking the affected areas in warm water for 1 5 minutes and then using a pumice stone to help dbride some of the dead skin. Th e patient can then apply topical salicylic acid liquid to the warts, let dry and cover with duct tape. The duct tape can be removed the following day and the p rocedure repeated if necessary. If he wishes, he may followup in 4-6 weeks for another treatment of liquid nitrogen, otherwise followup will be open-ended. Fo r the generalized xerosis of body, which is noted on the arms and legs especiall y, but also was on the trunk, face and neck, I have advised good moisturization to include an emollient moisturizer such as Vaseline, petroleum jelly and/or Cer aVe or Cetaphil body creams to be applied in a 50/50 mixture to all areas of the body on a 3-4 times daily basis. Adherence to this maybe a challenge; however, I have advised the patient s father that this would definitely be in his best int erest for help with the dryness of the skin. Follow up open-ended. The patient understands and accepts the risks, benefits and alternatives associa ted with the treatment.