human
Encounter Date: 04/24/2023
Physician Encounter

Office Visit

Chief Complaint: Itchy Scalp/Nurtec Questions TELEMEDICINE

History Of Present 45 YO AAF called today for telehealth consult.
Illness: Pt. states that she received a sample of Nurtec from the office and then has a prescription filled at her pharmacy. She was told there was a recall, so she made appointment to notify office of recall. Recall was on the packaging not the medication itself, pt. was advised by pharmacy that medication is okay to take. While on the phone, pt. states that she recently dyed her hair and not her scalp is itchy. She is requesting something to relief scalp and referral to dermatology. She also has acne that she would like evaluated by dermatology. today,

No other complaints
Medical History: HSV

Surgical History: L Bartholin cyst removed, 2012

Given the following document:

Family History: Father: Prostate cancer. Mother: heart disease.

Social History: Single, no children, self employed, bachelors degree, Denies any tobacco or illicit drug use. ETOH: social.

Physical Exam:

Constitutional: No PE due to nature of visit.

ASSESSMENT:
Diagnosis: ICD - 10 Codes:
1) L700 ; Acne vulgaris
2) L219 ; Seborrheic dermatitis, unspecified

PLAN:
Procedures: 1) 99212 ; Established Limited Eval
Medications: Ketoconazole 2 % External Shampoo: Apply I application externally weekly: Qty: 1 ; Refills: I
Care Plan: SCALP IRRITATION:
- Rx. for ketoconazole to assist with sxs. Instructed pt. to take OTC antihistamines to relieve itchiness. Avoid brand of hair dye in the future - Referral to dermatology per pt. request
ACNE:
Referral to dermatology
Patient Instructions: Pt understands and accepts above. RTC PRN
Referrals: Dermatology
---
What was the assessment?
Give a short answer and supply the relevant quote from the document above that supply the evidence for that answer. Use the following format
ANSWER
[the answer text]
QUOTE:
[the quote] 
gpt
--- Reasoning ---
1. Is the question multiple-choice question?
No
2. Is it implied multiple-choice question?
No
3. If two experts were independently asked the question, will the final answer be exactly the same?
Yes

--- Answer ---
grounded