🔬 DermSpX

note (synthesized)

- **Patient Information:**
  - Name: Howard Wynn
  - DOB: 02/15/1960
  - MRN: 14732
- **Past Medical History:**
  - ID=2660
  - Reason=ft follow up on nail at 4:10; patient was unable to receive rx  
  - Location=Entire Body
  - Cause=n/a
  - Notice=n/a
  - Problem=n/a
  - PriorTreatment=Yes, by Dr. Drugge
  - Past=acl reconstruction right and left knees 10 plus years ago, recurring lyme disease causing joint pain began 10/2022
  - SunContact=former lifeguard
- **Family History:**
  - ID=2660
  - Smoker=parents smoked
- **Pathology History (9 events):**
  - **2002-06-06:** nail toe — FUNGUS CULTURE:  MYCELEX MEDIUM  IS POSITIVE FOR GROWTH OF A  WHITE TO BEIGE COLONY WITH A DISCOLORATION OF THE MEDIUM C
  - **2002-06-06:** ? — PLEASE CALL THE PATIENT FOR CULTURE RESULTS    914-937-4473
  - **2003-04-01:** Posterior Neck — INTRADERMAL NEVUS, BENIGN
  - **2003-04-01:** nailtoe — FUNGAL CULTURE:  MYCELEX MEDIUM  IS POSITIVE FOR GROWTH OF A MUCOID WHITE COLONY WITHOUT SIGNIFICANT DISCOLORATION OF TH
  - **2003-04-01:** ? — TBU
  - **2003-05-01:** nail toe — FUNGAL CULTURE:  MYCELEX MEDIUM  IS POSITIVE FOR GROWTH OF A MUCOID WHITE COLONY WITHOUT SIGNIFICANT DISCOLORATION OF TH
  - **2003-05-01:** ? — TBU
  - **2024-04-12:** right shin — A-SKIN, RIGHT SHIN, SHAVE BIOPSY:LICHENOID DERMATITISNOTE: THE MICROSCOPIC DIFFERENTIAL DIAGNOSIS INCLUDES A LICHENOID D
  - **2024-04-12:** ? — TBU
- *Source: 9 extracted path events; 1 pathology PDFs on file. CSC pipeline data: see surveillance section above.*

rx (synthesized)

- **Active Medications:**
  - prednisone — 3mg
- **Recent Prescriptions:**
  - **2024-04-19:** Triamcinalone 0.1% Cream BID
  - **2023-08-25:** Ketoconazole 2% Cream BID
  - **2022-07-29:** terbinafine 250 mg P.O. daily for 12 weeks
  - **2022-07-29:** AST, ALT
  - **2021-07-14:** Terbinafine 250 mg p.o. Q.D. x three months
  - **2020-07-15:** Lamisil 250 mg po daily
  - **2018-07-20:** Valtrex 1 gm, two tabs P.O. now and in 12 hours
  - **2018-07-20:** Terbinafine 250 mg PO daily
  - **2018-07-20:** ALT(SGPT), AST(SGOT)
  - **2013-07-12:** HC 1%,Nystatin 25000 U/ml Shake lotion BID
  - **2011-07-29:** Valtrex 1 gm po daily
  - **2007-12-20:** Valtrex 1 gm P.O. daily.  For an acute attack, two tabs P.O. now and in 12 hours.
  - **2005-06-14:** Plaquenil 200 mg po BID
  - **2005-06-14:** Benzamycin Gel apply BID to affected areas
  - **2004-04-15:** Sporonox 100 mg two tabs p.o. BID x one week.

code (synthesized)

- **Recent ICD/CPT Codes:**
  - **2024-04-19:**
    - ICD: L27.1
    - CPT: 99213 Return Visit
  - **2024-04-12:**
    - ICD: L27.1, L40.0 Psoriasis Vulgaris
    - CPT: 11102 Tangential Biopsy, 99213 Return Visit
  - **2023-08-25:**
    - ICD: B35.3  Tinea pedis, D22.9 Melanocytic Nevi unspecified
    - CPT: 99213 Return Visit, 96904 Whole Body Integumentary Photography
  - **2022-07-29:**
    - ICD: D22.9 Melanocytic Nevi unspecified, D22.9 Melanocytic Nevi unspecified, B35.1 Tinea unguium
    - CPT: 99213 Return Visit, 96904 Whole Body Integumentary Photography
  - **2021-07-14:**
    - ICD: D22.9 Melanocytic Nevi unspecified, D22.9 Melanocytic Nevi unspecified, B35.9  Dermatophytosis,unsepcified
    - CPT: 99214 Return Visit, 96904 Whole Body Integumentary Photography
  - **2020-07-15:**
    - ICD: D22.9 Melanocytic Nevi unspecified, D22.9 Melanocytic Nevi unspecified, B35.1 Tinea unguium
    - CPT: 99214 Return Visit, 96904 Whole Body Integumentary Photography
  - **2018-07-20:**
    - ICD: D22.9 Melanocytic Nevi unspecified, D22.9 Melanocytic Nevi unspecified, B35.9  Dermatophytosis,unsepcified
    - CPT: 99214 Return Visit, 96904 Whole Body Integumentary Photography
  - **2015-10-02:**
    - ICD: D22.9 Melanocyte is Nevi unspecified
    - CPT: 99213 Return Visit
  - **2013-07-12:**
    - ICD: 216.9 Nevus, 112.3 Candidal Intertrigo
    - CPT: 99213 Return Visit
  - **2011-07-29:**
    - ICD: 216.9 Nevus
    - CPT: 99213 Return Visit
  - **2007-12-20:**
    - CPT: 96904 Whole Body Photography
  - **2006-05-23:**
    - ICD: 695.1 Erythema Multiforme, 695.1 Erythema Multiforme, 695.1 Erythema Multiforme
    - CPT: 99213 Return Visit, 90782 Injection, J1880 Kenalog (40 mg)

note (existing — what Dermatoscan reads now)

**Patient Information:**
- Name: Not provided
- Date of Birth: February 15, 1960
- Age: 64 years old (as of the latest visit in 2024)
- Gender: Male
- Marital Status: Married
- Occupation: Attorney
- Height: 5'6"
- Weight: 160 lbs
- Hair: Brown
- Eyes: Brown

**Medical History:**
- ACL reconstruction on both knees over 10 years ago.
- Recurring Lyme disease causing joint pain, began in October 2022.
- History of cold sores and light eruption.
- History of onychomycosis (toenail fungus).
- No personal history of skin cancer, but moderate skin cancer risk.
- Family history includes breast cancer in mother and prostate and lung cancer in father.
- No known drug allergies (NKDA).
- Medications: Prednisone 3mg for recurring Lyme disease and joint pain.

**Key Visits and Findings:**

1. **July 29, 2011:**
   - Annual skin check.
   - Over 50 nevi observed, none with significant atypia.
   - Diagnosed with recurrent herpes simplex on the right arm.
   - Prescribed Valtrex.

2. **July 12, 2013:**
   - Skin exam.
   - Over 50 nevi observed, none with significant atypia.
   - Complained of soreness in axillae; diagnosed with intertrigo.
   - Prescribed HC 1% and Nystatin lotion.

3. **October 2, 2015:**
   - Annual skin check.
   - Over 50 nevi observed, none with significant atypia.

4. **July 20, 2018:**
   - General skin exam and toe fungus.
   - Diagnosed with growing nevomelanocytic skin lesions and dysplastic nevus syndrome.
   - Onychomycosis confirmed; treated with Lamisil.

5. **July 15, 2020:**
   - Scan visit.
   - Over 50 nevi with significant atypia observed.
   - Onychomycosis confirmed; treated with terbinafine.

6. **August 25, 2023:**
   - Scan wait.
   - Over 50 nevi with significant atypia observed.
   - Diagnosed with growing nevomelanocytic skin lesions and dysplastic nevus syndrome.
   - Seborrhea and onycholysis noted.

7. **April 12, 2024:**
   - Follow-up for eczema.
   - Complained of eczema over the entire body.
   - Possible psoriasis secondary to hydroxychloroquine or drug reaction.
   - Plan to perform a skin biopsy and consult rheumatologist.

8. **April 19, 2024:**
   - Follow-up visit.
   - History of recurring Lyme disease and joint pain.
   - Lichenoid drug reaction likely caused by hydroxychloroquine.
   - Prescribed Triamcinolone cream for residual disease.

**Doctor's Findings:**
- The patient has a history of multiple nevi, some with atypia, but no significant risk for melanoma.
- Diagnosed with recurrent herpes simplex, intertrigo, onychomycosis, and dysplastic nevus syndrome.
- Recent issues include recurring Lyme disease, seborrhea, onycholysis, and possible psoriasis or eczema.
- Treatment plans have included antiviral medication, antifungal treatments, and topical corticosteroids.

rx (existing)

The prescription record for the patient under the care of dermatologist Dr. Drugge spans from 2002 to 2024. Over this period, the patient received various medications primarily for dermatological conditions, with a focus on antifungal and antiviral treatments, as well as topical creams for skin conditions.

1. **Antifungal Treatments:**
   - **Terbinafine:** Prescribed multiple times (2002, 2018, 2021, 2022) at a dosage of 250 mg daily, typically for a duration of three months, with no refills. This medication is used to treat fungal infections, particularly affecting the nails.
   - **Exelderm Solution:** Prescribed in 2003 for application twice daily to affected nails, with one refill.
   - **Sporonox (Itraconazole):** Prescribed in 2004 at 100 mg, two tablets twice daily for one week, with three refills.
   - **Lamisil (another brand of Terbinafine):** Prescribed in 2020 at 250 mg daily, with no refills.

2. **Antiviral Treatments:**
   - **Valtrex (Valacyclovir):** Prescribed in 2007, 2011, and 2018 for daily use, with specific instructions for acute attacks. The 2007 prescription included twelve refills, while the 2011 prescription had three refills.

3. **Topical Creams and Ointments:**
   - **Triamcinalone 0.1% Cream:** Prescribed in 2005 and 2024 for application twice daily, with varying refill amounts (twelve in 2005 and two in 2024).
   - **Benzamycin Gel:** Prescribed in 2005 for application twice daily to affected areas, with twelve refills.
   - **Protopic Ointment 0.03%:** Prescribed in 2007 for application twice daily, with six refills.
   - **Ketoconazole 2% Cream:** Prescribed in 2023 for application twice daily, with five refills.

4. **Other Treatments:**
   - **Plaquenil (Hydroxychloroquine):** Prescribed in 2005 for proactive use during trips, with one refill.
   - **Propecia (Finasteride):** Prescribed in 2005 for daily use, with four refills.
   - **HC 1% and Nystatin Lotion:** Prescribed in 2013 for application twice daily, with six refills.

5. **Laboratory Tests:**
   - **ALT and AST Tests:** Mentioned in prescriptions from 2018, 2021, and 2022, likely for monitoring liver function due to the use of systemic antifungal medications.

Overall, the patient's treatment plan involved a combination of oral and topical medications to manage fungal infections, viral outbreaks, and other dermatological conditions, with careful monitoring and adjustments over the years.

code (existing)

This record provides a detailed account of the dermatological encounters of a patient under the care of Dr. Drugge, spanning from 2002 to 2024. The record includes various ICD (International Classification of Diseases) and CPT (Current Procedural Terminology) codes, which document the diagnoses and procedures performed during each visit.

1. **2002-2004**: The patient was diagnosed with dermatophytosis (ICD 110.9) and atypical nevus (ICD 216.9). Procedures included an office consultation (CPT 99243) and a biopsy (CPT 11100). Return visits (CPT 99213) were common, indicating ongoing management of dermatophytosis and moniliasis (ICD 112.3).

2. **2005-2007**: The patient experienced polymorphous light eruption (ICD 692.72) and erythema multiforme (ICD 695.1). Treatment included return visits (CPT 99213) and an injection of Kenalog (CPT J1880). Whole body photography (CPT 96904) was performed in 2007, possibly for monitoring skin conditions.

3. **2011-2015**: The patient continued to have nevus (ICD 216.9) and melanocytic nevi (ICD D22.9). Return visits (CPT 99213) were consistent, indicating regular monitoring and management of these conditions.

4. **2018-2023**: The patient was diagnosed with dermatophytosis (ICD B35.9) and tinea unguium (ICD B35.1). Whole body integumentary photography (CPT 96904) was frequently used, suggesting a focus on comprehensive skin assessment. Return visits (CPT 99214) were slightly more frequent, indicating possibly more complex management.

5. **2024**: The patient presented with psoriasis vulgaris (ICD L40.0) and another unspecified condition (ICD L27.1). A tangential biopsy (CPT 11102) was performed, and return visits (CPT 99213) continued, reflecting ongoing care and evaluation of new or existing skin conditions.

Overall, the record reflects a long-term dermatological care plan involving regular monitoring, diagnostic procedures, and treatment adjustments for various skin conditions. The use of whole body photography and biopsies indicates a thorough approach to managing the patient's dermatological health.

Provenance