[doctor] uh , mrn49282721 . patient's name is jacqueline miller . use last visit exam where appropriate .
[doctor] hi , how are you doing , jacqueline ?
[patient] i'm pretty . good . how are you ?
[doctor] good as well . so it sounds like we're , um , under good control right now .
[patient] yes . it's doing much better .
[doctor] good , good . do you have any rash leftover ?
[patient] yeah , i have a- a small bit leftover . i started using , uh , doxycycline only one a day because i think the pharmacist said if it's getting better , to just limit it to once a day .
[doctor] okay , that sounds good .
[patient] but i was taking it twice a day and i did notice a lotta improvement .
[doctor] okay .
[patient] and then when i started doing it only once a day , it seems the same and it's not continuing to get better . so it's kinda plateaued a little bit .
[doctor] i see . um , are you breastfeeding at this time ?
[patient] no , i'm not right now .
[doctor] okay , good . so you- you should not be breastfeeding while you're on that medication .
[patient] yeah , actually i stopped breastfeeding and then asked for the doxycycline at that time .
[doctor] okay . even with the doxycycline , you can keep using the elidel .
[patient] okay . and i did n't take the elidel because when i read about it i got worried . so i wanted to just try the doxycycline and see .
[doctor] okay . so we can talk about the elidel . a lot of the things you read about is not actually relevant to the cream or ointment form , but it's about the oral form that's used in really high doses , longterm , after people have a heart transplant or a kidney transplant or something like that .
[patient] okay . i did n't realize that .
[doctor] yeah , and when you suppress the immune system that hard for that long , it can predispose you for developing cancers like hematologic type cancers . it does n't apply to as-needed use of the medicine , a cream or an ointment , okay ?
[patient] okay . then i can resume taking - taking the doxycycline twice a day again ?
[doctor] so let me clarify . what exactly are you using ? and then we'll look at you and figure out , okay ? so you're using the sulfacetamide wash ? uh , how frequently are you using that one ?
[patient] twice a day .
[doctor] okay , and that's not drying you out too much ?
[patient] no , that's fine .
[doctor] okay . and you're using the metro cream ?
[patient] yes .
[doctor] how often are you using that one ?
[patient] after my face wash , i immediately apply the cream .
[doctor] okay . and then , are you using any other kind of lotions or anything ?
[patient] no .
[doctor] so you're not using the cetaphil cleanser ?
[patient] i'm not .
[doctor] okay . and no neutrogena wipes ?
[patient] no wipes .
[doctor] okay . um , and then what about , um , any lotions that you're using ?
[patient] i'm not using any lotion right now , just those two .
[doctor] no lotion , okay . so that may be something else we should add in , a lotion to just help moisturize . but we'll see .
[patient] okay .
[doctor] um , and then again , when did you go down to just taking the doxycycline once a day ?
[patient] that was last week . so the first two weeks , i did twice a day .
[doctor] okay .
[patient] and then i started seeing improvement , and then i changed to just once a day .
[doctor] okay . let me take a look at your face here . i'm gon na describe for the transcriptionist what i'm seeing . you're fitzpatrick skin type iv , meaning you're not going to burn , you're going to sun tan , um , essentially , iv to v. and then on bilateral medial cheeks , there are a few really faint erythematous papules and just maybe a little bit of redness around and underneath your nostrils . so you're right , it's not totally gone .
[patient] yeah .
[doctor] i think i would go ahead and go back to twice a day , every day , with the doxycycline .
[patient] okay .
[doctor] uh , but i would pickup the elidel too .
[patient] okay , i can do that .
[doctor] i mean , out of known risks associated with medications , topicals are usually safer and preferable to oral medications . with that being said , doxycycline is low risk .
[patient] it is ? okay .
[doctor] um , and doxycycline can give you bad upset stomach or heartburn . um , it will make you sunburn , even if you never sunburn , so you have to protect yourself .
[patient] yeah , i mean , i feel sun sensitive whenever i go out , so i am taking all the precautions , with wearing a hat and all of that .
[doctor] great . i just wanted to make sure you knew about that .
[patient] yes , i did . thank you .
[doctor] all right . but i think to help get rid of it sooner rather than later , if insurance will cover the elidel , pick it up and start using it .
[patient] yeah , i did check . the insurance is not covering it .
[doctor] it's not ? okay . well , let's look around really quick because if you use a goodrx coupon , it will be around 30 to $ 40 or something .
[patient] okay .
[doctor] let's see .
[patient] so with your coupon , it was around $ 850 or something .
[doctor] ugh , yeah . that's way too much .
[patient] i agree . and- and because i also looked at the eucrisa that you recommended in my notes , and if it's still ex- if it's still expensive , i could try that instead .
[doctor] yeah , so it ... actually ... it is actually more expensive . i think the prices fluctuate .
[patient] okay .
[doctor] because now it's showing the cheapest of $ 70 , and when i looked before , it was around 30 to $ 40 .
[patient] yeah . if it was around $ 200 , i would've picked it up . but it was coming to around $ 850 after insurance .
[doctor] okay . so i've found the cream form . we could try ointment form .
[patient] you mean the tacrolimus ?
[doctor] yeah , mm-hmm .
[patient] okay .
[doctor] so if we send it to pick'n save or metro market ... let's see where else .
[patient] can you do the metro market ?
[doctor] yeah . let me put in the prescription and we'll see what we can find .
[patient] sure .
[doctor] pharmacy is what i'm trying to say .
[patient] okay . but it's not a steroid , right ?
[doctor] correct , it's not a steroid .
[patient] okay , good .
[doctor] it's called a calcineurin inhibitor . it's kinda like a steroid in that it calms inflammation .
[patient] okay .
[doctor] but it's not a steroid , so do n't use steroids on your face , for sure , as they'll make this kind of rash worse . but also , steroids carry the risk of causing thinning of the skin .
[patient] all right .
[doctor] these medications do n't cause thinning of the skin and they're not going to cause some other kind of rash . um , the thing to know is that sometimes five to 10 minutes after you put it on , it can cause this weird kind of tingly or needle-like sensation or make it redder or flush . but it should only last a few seconds and then go away . it's not an allergy or anything bad .
[patient] okay . got it .
[doctor] so it only lasts a couple seconds . it does n't mean it's going to happen again . it's nothing bad . it will still work , so keep using it as long as you know you can stand it , okay ?
[patient] okay , thank you for explaining .
[doctor] so i will say , " apply to rash on face twice daily , until resolved . "
[patient] okay . so only apply to the rash area ?
[doctor] yes , and keep using the face wash.
[patient] okay .
[doctor] i think you could just do it once a day . i do n't think you need to do it twice a day , just because i do n't wan na dry your sky out too much , okay ?
[patient] i never noticed that my face is dry or got thin . i feel so good after using it .
[doctor] i understand , but it could get dry and i do n't wan na create other problems for you .
[patient] all right . i'll just wash once a day with it . but it was feeling very good , like there's this little bit of moisture getting back in . with the other wash , when i would use it twice a day , i was drying out . but not with this one .
[doctor] i see . okay . well then do what feels good . if you do notice that you're starting to get dry , then reduce to once per day .
[patient] that sounds good .
[doctor] so to review , um , continue using the same face wash , continue with metro cream , and increase the use of doxycycline to twice a day .
[patient] okay .
[doctor] and then just do it until it's gone , and then do it for once a day for another week before stopping .
[patient] okay , sounds good .
[doctor] all right . and i'll rewrite your instructions here .
[patient] thank you so much .
[doctor] if there are any other questions or you're getting different instructions , feel free to reach out to me and we'll clarify , okay ?
[patient] okay .
[doctor] but in general , doxycycline is such a low risk . we're not gon na have you on this forever . but especially since we're adding the tacrolimus , i expect it will clear quickly .
[patient] sounds good .
[doctor] all right . and i just wan na really help knock it out as fast as possible , since you've been dealing with it for so long now . i would take it twice a day until it's gone , and then once a day for a week before you stop . i'll write it out like that . so twice a day until rash is gone , and then once a day for another week before stopping .
[patient] okay .
[doctor] once the rash stops , you can stop the tacrolimus ointment . um , continue doxycycline another week and then stop . but you can keep using the wash and the metro cream .
[patient] okay , that sounds good . i can do that .
[doctor] and then hold off until i see you again before you start back any of your old products . um , if it's starting to flair again , um , if it's just a little bit , you can try just doing the tacrolimus for a couple days , to see if that's enough . if it's not , then restart the dy- doxycycline as well .
[patient] all right .
[doctor] i do n't expect that to happen , but , you know , if it does , you have the tools . um , then you'll be seeing me for a followup . we can figure out what to do next . i would say if it's getting worse rather than better , just give me a call or send me a mychart message , okay ?
[patient] yeah , sounds good .
[doctor] do you have enough refills ?
[patient] yeah , i think so .
[doctor] okay . so it looks like you have another refill of the doxycycline , so you're good there . metro cream , you probably still have enough of that one .
[patient] yes , i do .
[doctor] all right . and i'll cancel the elidel cream , just so we do n't complicate your list . uh , you have plenty of the face wash still .
[patient] yes .
[doctor] okay . uh , and we'll get rid of the clindamycin from your list as well .
[patient] and what would you suggest for a moisturizer ?
[doctor] yeah , so for that i would do something really basic like vanicream . or even , if it's just really dry , you could use a little bit of petroleum jelly . um , i'll give you a couple samples , okay ? let's make sure we have a followup in about four weeks .
[patient] okay , thank you .
[doctor] okay . and i would stay away from any kind of anti-aging thing , any kind of plant thing . um , really let's just be sure we talk about any new products , or reach out to me if you're gon na try something else . um , let's go get those samples .
[patient] okay , that sounds good .
[doctor] for assessment and plan , perioral dermatitis , rosacea , including ocular rosacea , and copy and paste her patient instructions . i recommend that she gently wash her eyelids once a day with gentle cleanser such as vanicream , also use bruder mask as needed .

Medical orders:
description: followup in about four weeks
order_type: followup
description: ointment tacrolimus apply to rash on fac until resolved
order_type: medication
description: ointment tacrolimus until rash is gone stop
order_type: medication
description: doxycycline until rash is gone
order_type: medication
description: twice a day every day doxycycline once a day for another week
order_type: medication