Dashboard
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Origination
| Notes | Grading Score | Status | |
|---|---|---|---|
| Patient Name: Jane Doe DOB: 03/15/1995 Age: 30 years Sex: Female Date of Service: 03/10/2025 Location: New York Dermatology Clinic Chief Complaint Patient presents with a persistent facial rash and photosensitivity with occasional joint discomfort. History of Present Illness Jane Doe is a 30-year-old female who reports a 6-week history of an erythematous, scaly rash predominantly over the malar region, extending to the nasal bridge, with sparing of the nasolabial folds. The rash is mildly pruritic and worsens with sun exposure. In addition, she describes intermittent joint pains in her hands and knees, which she rates as mild-to-moderate in intensity. There is no history of fever, oral ulcers, or significant weight loss. The patient notes that the rash has not improved with over-the-counter moisturizers. She denies any new skincare products, exposures, or recent infections. The distribution and characteristics of the rash raise concern for an underlying autoimmune process, potentially cutaneous lupus erythematosus, warranting further laboratory evaluation. Past Medical History Hypothyroidism: Diagnosed 5 years ago, well-controlled on levothyroxine. No known history of dermatologic conditions prior to this episode. Past Surgical History Appendectomy: Performed at age 15, no complications. Medications Levothyroxine 75 mcg daily Combined Oral Contraceptive Pill (for birth control and menstrual regulation) Allergies NKDA (No known drug allergies) Family History Mother: Rheumatoid arthritis Sister: Hashimoto’s thyroiditis No known family history of systemic lupus erythematosus Social History Occupation: Administrative professional in New York City Lifestyle: Non-smoker, occasional alcohol use Exercise: Regular (3 times/week moderate activity) Sun Exposure: Increased due to outdoor commuting; uses minimal sunscreen Review of Systems Constitutional: Denies fever, chills, or fatigue. Skin: Reports rash as described; no new lesions on other parts of the body. Musculoskeletal: Intermittent joint pain in hands and knees, without significant swelling. HEENT: No oral ulcers, no vision changes; mild photosensitivity noted. Cardiovascular/Respiratory: Negative. Gastrointestinal/Genitourinary: Negative. Neurological: Negative. Psychiatric: Denies depression or anxiety related to her condition. Physical Examination Vital Signs: Temperature: 98.6°F Blood Pressure: 118/76 mmHg Pulse: 72 bpm Respirations: 16/min General: Alert, well-appearing female in no acute distress. Skin: Face: Erythematous, slightly edematous rash over the malar region with fine scale, sparing the nasolabial folds. No vesicles or pustules noted. Extremities & Trunk: No rashes or lesions observed. Musculoskeletal: Mild tenderness on palpation of the small joints of the hands without obvious swelling or deformity. Full range of motion maintained. HEENT: Head: Normocephalic, atraumatic. Eyes: Conjunctiva clear; sclera anicteric. Oral Mucosa: No lesions or ulcers. Assessment Suspected Cutaneous Lupus Erythematosus (CLE): Discoid lupus erythematosus or Systemic lupus erythematosus if systemic involvement is confirmed. Differential includes: photosensitive dermatitis, rosacea, and seborrheic dermatitis. Joint Pain: Likely inflammatory in nature, possibly related to autoimmune etiology. Hypothyroidism (Controlled): No changes in management required at this time. Plan Diagnostic Work-Up: Laboratory Tests: Antinuclear Antibody (ANA) Panel: To screen for autoimmune markers. Anti-dsDNA and Anti-Sm antibodies: Specific markers for lupus. CBC with Differential and CMP: To assess for systemic involvement and inflammation. Complement Levels (C3, C4): To evaluate immune activity. Phototesting: Consider referral if diagnosis remains unclear. Therapeutic Management: Topical Therapy: Initiate a mid-potency topical corticosteroid (e.g., triamcinolone acetonide 0.1% cream) to be applied twice daily to affected areas for 4 weeks. Recommend a non-comedogenic moisturizer. Sun Protection: Advise strict photoprotection measures including broad-spectrum sunscreen (SPF 50+), protective clothing, and avoiding peak sun hours. Joint Pain Management: Initiate NSAIDs (e.g., ibuprofen 400 mg every 6-8 hours as needed) for symptomatic relief. Patient Education: Discuss the potential autoimmune nature of her condition, the need for further evaluation, and the importance of sun protection. Educate on the possibility of systemic involvement and the need for follow-up if symptoms escalate. Follow-Up: Schedule a follow-up appointment in 4 weeks to review lab results, assess response to topical therapy, and re-evaluate joint symptoms. Provide instructions to contact the clinic sooner if she experiences worsening symptoms, new systemic manifestations, or adverse reactions to medications. | 5 | Completed |  |
| Patient Name: Jane Doe DOB: 03/15/1995 Age: 30 years Sex: Female Date of Service: 03/10/2025 Location: New York Dermatology Clinic Chief Complaint Patient presents with a persistent facial rash and photosensitivity with occasional joint discomfort. History of Present Illness Jane Doe is a 30-year-old female who reports a 6-week history of an erythematous, scaly rash predominantly over the malar region, extending to the nasal bridge, with sparing of the nasolabial folds. The rash is mildly pruritic and worsens with sun exposure. In addition, she describes intermittent joint pains in her hands and knees, which she rates as mild-to-moderate in intensity. There is no history of fever, oral ulcers, or significant weight loss. The patient notes that the rash has not improved with over-the-counter moisturizers. She denies any new skincare products, exposures, or recent infections. The distribution and characteristics of the rash raise concern for an underlying autoimmune process, potentially cutaneous lupus erythematosus, warranting further laboratory evaluation. Past Medical History Hypothyroidism: Diagnosed 5 years ago, well-controlled on levothyroxine. No known history of dermatologic conditions prior to this episode. Past Surgical History Appendectomy: Performed at age 15, no complications. Medications Levothyroxine 75 mcg daily Combined Oral Contraceptive Pill (for birth control and menstrual regulation) Allergies NKDA (No known drug allergies) Family History Mother: Rheumatoid arthritis Sister: Hashimoto’s thyroiditis No known family history of systemic lupus erythematosus Social History Occupation: Administrative professional in New York City Lifestyle: Non-smoker, occasional alcohol use Exercise: Regular (3 times/week moderate activity) Sun Exposure: Increased due to outdoor commuting; uses minimal sunscreen Review of Systems Constitutional: Denies fever, chills, or fatigue. Skin: Reports rash as described; no new lesions on other parts of the body. Musculoskeletal: Intermittent joint pain in hands and knees, without significant swelling. HEENT: No oral ulcers, no vision changes; mild photosensitivity noted. Cardiovascular/Respiratory: Negative. Gastrointestinal/Genitourinary: Negative. Neurological: Negative. Psychiatric: Denies depression or anxiety related to her condition. Physical Examination Vital Signs: Temperature: 98.6°F Blood Pressure: 118/76 mmHg Pulse: 72 bpm Respirations: 16/min General: Alert, well-appearing female in no acute distress. Skin: Face: Erythematous, slightly edematous rash over the malar region with fine scale, sparing the nasolabial folds. No vesicles or pustules noted. Extremities & Trunk: No rashes or lesions observed. Musculoskeletal: Mild tenderness on palpation of the small joints of the hands without obvious swelling or deformity. Full range of motion maintained. HEENT: Head: Normocephalic, atraumatic. Eyes: Conjunctiva clear; sclera anicteric. Oral Mucosa: No lesions or ulcers. Assessment Suspected Cutaneous Lupus Erythematosus (CLE): Discoid lupus erythematosus or Systemic lupus erythematosus if systemic involvement is confirmed. Differential includes: photosensitive dermatitis, rosacea, and seborrheic dermatitis. Joint Pain: Likely inflammatory in nature, possibly related to autoimmune etiology. Hypothyroidism (Controlled): No changes in management required at this time. Plan Diagnostic Work-Up: Laboratory Tests: Antinuclear Antibody (ANA) Panel: To screen for autoimmune markers. Anti-dsDNA and Anti-Sm antibodies: Specific markers for lupus. CBC with Differential and CMP: To assess for systemic involvement and inflammation. Complement Levels (C3, C4): To evaluate immune activity. Phototesting: Consider referral if diagnosis remains unclear. Therapeutic Management: Topical Therapy: Initiate a mid-potency topical corticosteroid (e.g., triamcinolone acetonide 0.1% cream) to be applied twice daily to affected areas for 4 weeks. Recommend a non-comedogenic moisturizer. Sun Protection: Advise strict photoprotection measures including broad-spectrum sunscreen (SPF 50+), protective clothing, and avoiding peak sun hours. Joint Pain Management: Initiate NSAIDs (e.g., ibuprofen 400 mg every 6-8 hours as needed) for symptomatic relief. Patient Education: Discuss the potential autoimmune nature of her condition, the need for further evaluation, and the importance of sun protection. Educate on the possibility of systemic involvement and the need for follow-up if symptoms escalate. Follow-Up: Schedule a follow-up appointment in 4 weeks to review lab results, assess response to topical therapy, and re-evaluate joint symptoms. Provide instructions to contact the clinic sooner if she experiences worsening symptoms, new systemic manifestations, or adverse reactions to medications. | 5 | Completed | |
| Patient Name: Jane Doe DOB: 03/15/1995 Age: 30 years Sex: Female Date of Service: 03/10/2025 Location: New York Dermatology Clinic Chief Complaint Patient presents with a persistent facial rash and photosensitivity with occasional joint discomfort. History of Present Illness Jane Doe is a 30-year-old female who reports a 6-week history of an erythematous, scaly rash predominantly over the malar region, extending to the nasal bridge, with sparing of the nasolabial folds. The rash is mildly pruritic and worsens with sun exposure. In addition, she describes intermittent joint pains in her hands and knees, which she rates as mild-to-moderate in intensity. There is no history of fever, oral ulcers, or significant weight loss. The patient notes that the rash has not improved with over-the-counter moisturizers. She denies any new skincare products, exposures, or recent infections. The distribution and characteristics of the rash raise concern for an underlying autoimmune process, potentially cutaneous lupus erythematosus, warranting further laboratory evaluation. Past Medical History Hypothyroidism: Diagnosed 5 years ago, well-controlled on levothyroxine. No known history of dermatologic conditions prior to this episode. Past Surgical History Appendectomy: Performed at age 15, no complications. Medications Levothyroxine 75 mcg daily Combined Oral Contraceptive Pill (for birth control and menstrual regulation) Allergies NKDA (No known drug allergies) Family History Mother: Rheumatoid arthritis Sister: Hashimoto’s thyroiditis No known family history of systemic lupus erythematosus Social History Occupation: Administrative professional in New York City Lifestyle: Non-smoker, occasional alcohol use Exercise: Regular (3 times/week moderate activity) Sun Exposure: Increased due to outdoor commuting; uses minimal sunscreen Review of Systems Constitutional: Denies fever, chills, or fatigue. Skin: Reports rash as described; no new lesions on other parts of the body. Musculoskeletal: Intermittent joint pain in hands and knees, without significant swelling. HEENT: No oral ulcers, no vision changes; mild photosensitivity noted. Cardiovascular/Respiratory: Negative. Gastrointestinal/Genitourinary: Negative. Neurological: Negative. Psychiatric: Denies depression or anxiety related to her condition. Physical Examination Vital Signs: Temperature: 98.6°F Blood Pressure: 118/76 mmHg Pulse: 72 bpm Respirations: 16/min General: Alert, well-appearing female in no acute distress. Skin: Face: Erythematous, slightly edematous rash over the malar region with fine scale, sparing the nasolabial folds. No vesicles or pustules noted. Extremities & Trunk: No rashes or lesions observed. Musculoskeletal: Mild tenderness on palpation of the small joints of the hands without obvious swelling or deformity. Full range of motion maintained. HEENT: Head: Normocephalic, atraumatic. Eyes: Conjunctiva clear; sclera anicteric. Oral Mucosa: No lesions or ulcers. Assessment Suspected Cutaneous Lupus Erythematosus (CLE): Discoid lupus erythematosus or Systemic lupus erythematosus if systemic involvement is confirmed. Differential includes: photosensitive dermatitis, rosacea, and seborrheic dermatitis. Joint Pain: Likely inflammatory in nature, possibly related to autoimmune etiology. Hypothyroidism (Controlled): No changes in management required at this time. Plan Diagnostic Work-Up: Laboratory Tests: Antinuclear Antibody (ANA) Panel: To screen for autoimmune markers. Anti-dsDNA and Anti-Sm antibodies: Specific markers for lupus. CBC with Differential and CMP: To assess for systemic involvement and inflammation. Complement Levels (C3, C4): To evaluate immune activity. Phototesting: Consider referral if diagnosis remains unclear. Therapeutic Management: Topical Therapy: Initiate a mid-potency topical corticosteroid (e.g., triamcinolone acetonide 0.1% cream) to be applied twice daily to affected areas for 4 weeks. Recommend a non-comedogenic moisturizer. Sun Protection: Advise strict photoprotection measures including broad-spectrum sunscreen (SPF 50+), protective clothing, and avoiding peak sun hours. Joint Pain Management: Initiate NSAIDs (e.g., ibuprofen 400 mg every 6-8 hours as needed) for symptomatic relief. Patient Education: Discuss the potential autoimmune nature of her condition, the need for further evaluation, and the importance of sun protection. Educate on the possibility of systemic involvement and the need for follow-up if symptoms escalate. Follow-Up: Schedule a follow-up appointment in 4 weeks to review lab results, assess response to topical therapy, and re-evaluate joint symptoms. Provide instructions to contact the clinic sooner if she experiences worsening symptoms, new systemic manifestations, or adverse reactions to medications. | 5 | Completed | |
| Patient Name: Jane Doe DOB: 03/15/1995 Age: 30 years Sex: Female Date of Service: 03/10/2025 Location: New York Dermatology Clinic Chief Complaint Patient presents with a persistent facial rash and photosensitivity with occasional joint discomfort. History of Present Illness Jane Doe is a 30-year-old female who reports a 6-week history of an erythematous, scaly rash predominantly over the malar region, extending to the nasal bridge, with sparing of the nasolabial folds. The rash is mildly pruritic and worsens with sun exposure. In addition, she describes intermittent joint pains in her hands and knees, which she rates as mild-to-moderate in intensity. There is no history of fever, oral ulcers, or significant weight loss. The patient notes that the rash has not improved with over-the-counter moisturizers. She denies any new skincare products, exposures, or recent infections. The distribution and characteristics of the rash raise concern for an underlying autoimmune process, potentially cutaneous lupus erythematosus, warranting further laboratory evaluation. Past Medical History Hypothyroidism: Diagnosed 5 years ago, well-controlled on levothyroxine. No known history of dermatologic conditions prior to this episode. Past Surgical History Appendectomy: Performed at age 15, no complications. Medications Levothyroxine 75 mcg daily Combined Oral Contraceptive Pill (for birth control and menstrual regulation) Allergies NKDA (No known drug allergies) Family History Mother: Rheumatoid arthritis Sister: Hashimoto’s thyroiditis No known family history of systemic lupus erythematosus Social History Occupation: Administrative professional in New York City Lifestyle: Non-smoker, occasional alcohol use Exercise: Regular (3 times/week moderate activity) Sun Exposure: Increased due to outdoor commuting; uses minimal sunscreen Review of Systems Constitutional: Denies fever, chills, or fatigue. Skin: Reports rash as described; no new lesions on other parts of the body. Musculoskeletal: Intermittent joint pain in hands and knees, without significant swelling. HEENT: No oral ulcers, no vision changes; mild photosensitivity noted. Cardiovascular/Respiratory: Negative. Gastrointestinal/Genitourinary: Negative. Neurological: Negative. Psychiatric: Denies depression or anxiety related to her condition. Physical Examination Vital Signs: Temperature: 98.6°F Blood Pressure: 118/76 mmHg Pulse: 72 bpm Respirations: 16/min General: Alert, well-appearing female in no acute distress. Skin: Face: Erythematous, slightly edematous rash over the malar region with fine scale, sparing the nasolabial folds. No vesicles or pustules noted. Extremities & Trunk: No rashes or lesions observed. Musculoskeletal: Mild tenderness on palpation of the small joints of the hands without obvious swelling or deformity. Full range of motion maintained. HEENT: Head: Normocephalic, atraumatic. Eyes: Conjunctiva clear; sclera anicteric. Oral Mucosa: No lesions or ulcers. Assessment Suspected Cutaneous Lupus Erythematosus (CLE): Discoid lupus erythematosus or Systemic lupus erythematosus if systemic involvement is confirmed. Differential includes: photosensitive dermatitis, rosacea, and seborrheic dermatitis. Joint Pain: Likely inflammatory in nature, possibly related to autoimmune etiology. Hypothyroidism (Controlled): No changes in management required at this time. Plan Diagnostic Work-Up: Laboratory Tests: Antinuclear Antibody (ANA) Panel: To screen for autoimmune markers. Anti-dsDNA and Anti-Sm antibodies: Specific markers for lupus. CBC with Differential and CMP: To assess for systemic involvement and inflammation. Complement Levels (C3, C4): To evaluate immune activity. Phototesting: Consider referral if diagnosis remains unclear. Therapeutic Management: Topical Therapy: Initiate a mid-potency topical corticosteroid (e.g., triamcinolone acetonide 0.1% cream) to be applied twice daily to affected areas for 4 weeks. Recommend a non-comedogenic moisturizer. Sun Protection: Advise strict photoprotection measures including broad-spectrum sunscreen (SPF 50+), protective clothing, and avoiding peak sun hours. Joint Pain Management: Initiate NSAIDs (e.g., ibuprofen 400 mg every 6-8 hours as needed) for symptomatic relief. Patient Education: Discuss the potential autoimmune nature of her condition, the need for further evaluation, and the importance of sun protection. Educate on the possibility of systemic involvement and the need for follow-up if symptoms escalate. Follow-Up: Schedule a follow-up appointment in 4 weeks to review lab results, assess response to topical therapy, and re-evaluate joint symptoms. Provide instructions to contact the clinic sooner if she experiences worsening symptoms, new systemic manifestations, or adverse reactions to medications. | 0 | Created | |
| Below is the reformatted clinical note in the standardized template using the provided transcript information. Since the original note did not provide any specific data for each section, the fields have been marked accordingly. Patient Information - No patient information provided. Chief Complaint - No chief complaint provided. History of Present Illness (HPI) - Onset: Not documented - Location: Not documented - Duration: Not documented - Character: Not documented - Aggravating/Relieving Factors: Not documented - Timing: Not documented - Severity: Not documented - Narrative: No information available. Past Medical History (PMH) - Not documented. Review of Systems (ROS) - Not documented. Physical Examination - Vital Signs: Not documented - Pertinent Findings: No physical examination information provided. Assessment / Diagnosis - No assessment or diagnosis information provided. Plan / Treatment - No plan or treatment information discussed. Additional Documentation - Informed Consent: Not documented - Risk Assessment: Not documented - Signature/Date: Not documented Quality Grade: Low quality note – the transcript lacked sufficient clinical information. Additional Questions for Improvement: 1. Can further patient details or a more comprehensive transcript be provided to enhance the clinical documentation? 2. Is there a possibility to obtain the patient’s chief complaint and additional history details to complete the HPI? 3. Would additional context about the physical exam, assessment, and plan be available to improve the overall narrative? This documentation strictly follows the provided content without adding any additional clinical data. | 0 | Completed | |
| **SOAP Clinical Notes** **S: Subjective** - Patient reports having a "not relaxing night." - Expresses feelings of not feeling good at times. - Mentions waking up feeling fresh and interested, but also describes experiencing little interest and pleasure in activities, indicating feelings of being down. - Reports trouble relaxing and expresses fear about certain things. **O: Objective** - No objective findings were documented during the conversation. **A: Assessment** - The patient appears to be experiencing symptoms consistent with mood disturbances, including feelings of sadness, lack of interest, and difficulty relaxing. Further evaluation may be necessary to assess the severity and underlying causes of these symptoms. **P: Plan** - Continue to monitor the patient's mood and emotional state. - Consider discussing coping strategies for relaxation and managing fears in future sessions. - Schedule a follow-up appointment to reassess the patient's condition and response to any interventions. | 3 | Completed | |
| Patient Name: Jane Doe DOB: 03/15/1995 Age: 30 years Sex: Female Date of Service: 03/10/2025 Location: New York Dermatology Clinic Chief Complaint Patient presents with a persistent facial rash and photosensitivity with occasional joint discomfort. History of Present Illness Jane Doe is a 30-year-old female who reports a 6-week history of an erythematous, scaly rash predominantly over the malar region, extending to the nasal bridge, with sparing of the nasolabial folds. The rash is mildly pruritic and worsens with sun exposure. In addition, she describes intermittent joint pains in her hands and knees, which she rates as mild-to-moderate in intensity. There is no history of fever, oral ulcers, or significant weight loss. The patient notes that the rash has not improved with over-the-counter moisturizers. She denies any new skincare products, exposures, or recent infections. The distribution and characteristics of the rash raise concern for an underlying autoimmune process, potentially cutaneous lupus erythematosus, warranting further laboratory evaluation. Past Medical History Hypothyroidism: Diagnosed 5 years ago, well-controlled on levothyroxine. No known history of dermatologic conditions prior to this episode. Past Surgical History Appendectomy: Performed at age 15, no complications. Medications Levothyroxine 75 mcg daily Combined Oral Contraceptive Pill (for birth control and menstrual regulation) Allergies NKDA (No known drug allergies) Family History Mother: Rheumatoid arthritis Sister: Hashimoto’s thyroiditis No known family history of systemic lupus erythematosus Social History Occupation: Administrative professional in New York City Lifestyle: Non-smoker, occasional alcohol use Exercise: Regular (3 times/week moderate activity) Sun Exposure: Increased due to outdoor commuting; uses minimal sunscreen Review of Systems Constitutional: Denies fever, chills, or fatigue. Skin: Reports rash as described; no new lesions on other parts of the body. Musculoskeletal: Intermittent joint pain in hands and knees, without significant swelling. HEENT: No oral ulcers, no vision changes; mild photosensitivity noted. Cardiovascular/Respiratory: Negative. Gastrointestinal/Genitourinary: Negative. Neurological: Negative. Psychiatric: Denies depression or anxiety related to her condition. Physical Examination Vital Signs: Temperature: 98.6°F Blood Pressure: 118/76 mmHg Pulse: 72 bpm Respirations: 16/min General: Alert, well-appearing female in no acute distress. Skin: Face: Erythematous, slightly edematous rash over the malar region with fine scale, sparing the nasolabial folds. No vesicles or pustules noted. Extremities & Trunk: No rashes or lesions observed. Musculoskeletal: Mild tenderness on palpation of the small joints of the hands without obvious swelling or deformity. Full range of motion maintained. HEENT: Head: Normocephalic, atraumatic. Eyes: Conjunctiva clear; sclera anicteric. Oral Mucosa: No lesions or ulcers. Assessment Suspected Cutaneous Lupus Erythematosus (CLE): Discoid lupus erythematosus or Systemic lupus erythematosus if systemic involvement is confirmed. Differential includes: photosensitive dermatitis, rosacea, and seborrheic dermatitis. Joint Pain: Likely inflammatory in nature, possibly related to autoimmune etiology. Hypothyroidism (Controlled): No changes in management required at this time. Plan Diagnostic Work-Up: Laboratory Tests: Antinuclear Antibody (ANA) Panel: To screen for autoimmune markers. Anti-dsDNA and Anti-Sm antibodies: Specific markers for lupus. CBC with Differential and CMP: To assess for systemic involvement and inflammation. Complement Levels (C3, C4): To evaluate immune activity. Phototesting: Consider referral if diagnosis remains unclear. Therapeutic Management: Topical Therapy: Initiate a mid-potency topical corticosteroid (e.g., triamcinolone acetonide 0.1% cream) to be applied twice daily to affected areas for 4 weeks. Recommend a non-comedogenic moisturizer. Sun Protection: Advise strict photoprotection measures including broad-spectrum sunscreen (SPF 50+), protective clothing, and avoiding peak sun hours. Joint Pain Management: Initiate NSAIDs (e.g., ibuprofen 400 mg every 6-8 hours as needed) for symptomatic relief. Patient Education: Discuss the potential autoimmune nature of her condition, the need for further evaluation, and the importance of sun protection. Educate on the possibility of systemic involvement and the need for follow-up if symptoms escalate. Follow-Up: Schedule a follow-up appointment in 4 weeks to review lab results, assess response to topical therapy, and re-evaluate joint symptoms. Provide instructions to contact the clinic sooner if she experiences worsening symptoms, new systemic manifestations, or adverse reactions to medications. | 5 | Completed | |