Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Hyperesthesia

Description: Patient comes in for initial evaluation of a hyperesthesia on his right abdomen.
(Medical Transcription Sample Report)


SUBJECTIVE: This 49-year-old white male, established patient in dermatology, last seen in the office on 08/02/2002, comes in today for initial evaluation of a hyperesthesia on his right abdomen, then on his left abdomen, then on his left medial thigh. It cleared for awhile. This has been an intermittent problem. Now it is back again on his right lower abdomen. At first, it was thought that he may have early zoster. This started six weeks before the holidays and is still going on, more so in the past eight days on his abdomen and right hip area. He has had no treatment on this; there are no skin changes at all. The patient bathes everyday but tries to use little soap. The patient is married. He works as an airplane mechanic.

FAMILY, SOCIAL, AND ALLERGY HISTORY: The patient has sinus and CVA. He is a nonsmoker. No known drug allergies.

CURRENT MEDICATIONS: Lipitor, aspirin, folic acid.

PHYSICAL EXAMINATION: The patient is well developed, appears stated age. Overall health is good. He does have psoriasis with some psoriatic arthritis, and his skin looks normal today. On his trunk, he does have the hyperesthesia. As you touch him, he winces.

IMPRESSION: Hyperesthesia, question etiology.

TREATMENT:
1. Discussed condition and treatment with the patient.
2. Discontinue hot soapy water to these areas.
3. Increase moisturizing cream and lotion.
4. I referred him to Dr. ABC or Dr. XYZ for neurology evaluation. We did not see anything on skin today. Return p.r.n. flare.

Keywords: consult - history and phy., dermatology, abdomen, hyperesthesia, soapy water, moisturizing cream, initial evaluation,