Skin Progress Note Template

Drugs and Their Uses

Hydrocortisone

Hydrocortisone reduces inflammation and irritation caused by conditions like eczema or dermatitis. It helps alleviate redness, swelling, and discomfort, making it effective for mild to moderate skin conditions (Hodgens & Sharman, 2023).

Prednisone

Prednisone, a corticosteroid, is prescribed for severe skin inflammations, autoimmune-related conditions, and persistent rashes (Y et al., 2020). It is commonly used to manage eczema or psoriasis, providing relief from more intense symptoms.

Neosporin

Neosporin, an antibiotic ointment, is applied to wounds, cuts, and biopsy sites to prevent infection and promote faster healing. It is essential for reducing the risk of complications after skin procedures.

References

Hodgens, A., & Sharman, T. (2023, May 1). Corticosteroids. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK554612/

Y, P., A, G., & Aa, B. (2020, January 1). Prednisone. PubMed. https://pubmed.ncbi.nlm.nih.gov/30521230/

Zito, P. M., & Scharf, R. (2020). Cyst, Epidermoid (Sebaceous Cyst). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499974/

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Change the medical terms in a progress note for a patient with a skin condition into common terms. Spell all medical and common terms correctly on the provided template.

Introduction
The first step in completing this assessment is to review how to build a medical term. A medical term is built from three parts. The first part is the prefix or the beginning of the word. The second part is the word root or the main part of the word. The last part is the suffix or the ending of the word.

This assessment also covers the following body systems:

• Musculoskeletal
  • Definition: Is the muscles and bones
• Integumentary
  • Definition: Is the skin.

Then you will examine the skin, muscles, and bone systems. You will focus on diagnosis and treatment of the skin system. The skin is the largest organ of the body, with a total area of about 20 square feet. The skin protects us from microbes and the elements, helps regulate body temperature, and permits the sensations of touch, heat, and cold.

In the assessment, you will review a progress note. Progress notes are common documents found in health care records in doctors’ offices and in hospitals. The first step is to identify the medical terms in the progress note. Then, you will change the medical terms that you found into common terms.

Your suggested resources provide study tips, explain the structure of medical terminology, and address skin, muscles, and bones conditions, diseases, treatment, and diagnostic studies.

Instructions
Review the progress note below, including the subjective and objective notations. Next, download the Skin Progress Note Template [DOCX] (attached) and complete all of the following on the template:

• Select 12 medical terms from the progress note.
• On the template, place one term per line. For example: Actinic keratosis should not be on the same line, Actinic should be on one line and keratosis on a second line.
• Change the 12 selected medical terms into commonly used terms.
• Use medical terminology skills to break the medical term into its word parts. For example: keratosis is kerato, which means horny tissue and osis, which means condition of. Putting these together, keratosis means condition of horny tissue
• Select three drugs from the progress note. For each drug, identify a skin condition that the selected drug treats.
• Spell all medical terms, common terms, and drugs correctly.

Skin Progress Note
Subjective: The patient is a 49-year-old female who comes in with the complaint of having bumps on her arms. She states some of the bumps have been there a long time. Recently the bumps have been increasing in number and size. She was last seen about two years ago for eczema and was prescribed cyclosporine, at that time. However, she did not have these bumps. The bumps are not itchy or painful.

Objective: Very pleasant, alert, and oriented x3 female in no apparent distress. A full integumentary exam of the upper arms was performed today. The left radial aspect demonstrated erythematous macules. The right ulnar aspect demonstrated actinic keratosis.

Bilateral hands appeared dry with linear excoriation and fissuring of her fingertips. Bilateral upper arms demonstrated superficial and deep masses. Deep subcutaneous masses are mobile and may represent lipomas. Superficial masses appear to be sebaceous cysts.

Assessment and Plan:

1. Actinic keratosis of the right ulnar aspect was treated with liquid nitrogen.
2. Possible lipomas: Schedule surgical biopsy of larger masses.
3. Sebaceous cysts: Punch biopsy performed today; await pathology report. Apply Neosporin to biopsy site.
4. Start Hydrocortisone intensive cream.
5. Start Prednisone as directed.
   

   Skin Progress Note Template

Additional Requirements

• Format: Ensure you complete all columns on the Skin Progress Note Template.
• Scoring Guide: Be sure to read the scoring guide for this assessment to understand how your faculty member will evaluate your work.

Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

• Competency 1: Use medical terminology and abbreviations related to pharmacology.
  • Identify drugs correctly.
  • Specify the correct reason for the drug’s use.
• Competency 2: Use medical terminology and abbreviations related to general structures and functions of the human body.
  • Identify medical terms related to general structures and functions of the human body correctly.
  • Change medical terms related to general structures and functions of the human body into common terms correctly.
• Competency 3: Use medical terminology and abbreviations related to body systems.
  • Identify medical terms related to body systems correctly.
  • Change medical terms related to body systems into common terms correctly.
• Competency 6: Spell and pronounce basic medical terms.
  • Spell medical and common terms correctly.