DATE OF SERVICE: MM/DD/YYYY
CHIEF COMPLAINT: Followup skin check.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old Asian woman with significant past medical history of squamous cell carcinoma on the left infraorbital region, status post Mohs surgery. She also has a history of multiple basal cell carcinomas, previously treated at outside facilities, but does not remember exactly where they were or when they were treated. She also has a history of actinic keratoses, which has been treated in the past with cryotherapy as well as Efudex, and most recent Efudex treatment was in MM/DD/YYYY on the face and neck for persistent AKs. She also had a verruca treated in the past. She does note today one papule on her left plantar foot. She states that has been there for several months but does not give her symptoms.
PAST MEDICAL HISTORY: As per HPI as well as temporal arteritis.
MEDICATIONS: Updated and reviewed.
ALLERGIES: SULFA.
REVIEW OF SYSTEMS: The patient denies any fevers, chills, nausea, vomiting, weight changes or blurry vision.
PHYSICAL EXAMINATION:
GENERAL: The patient is alert and oriented x3 and has pleasant, appropriate affect and mood.
GENERAL APPEARANCE: The patient is a well-developed, well-nourished female in no acute distress, who appears stated age.
VITAL SIGNS: Pulse 66, respiratory rate 18, and blood pressure 134/72.
SKIN: A full skin examination was performed today, including the head, face, neck, chest, breast, back, axillae, abdomen, arms, hands, legs, feet, digits, nails, groin, and buttocks. Eyelids and conjunctivae were clear. Oral mucosa and lips showed no pigmented lesions. Scalp, trunk, extremities, and digits were palpated. No appreciated clubbing or cyanosis.
Of note, on examination, the patient has multiple skin-colored, stuck-on papules and plaques located on the scalp, face, trunk, as well as upper and lower extremities. She also has around fourteen 1 to 4 mm brown macules consistent with benign melanocytic nevi. No concerning features on dermoscopy. On the right clavicle area seen is a 4 mm erythematous papule with C-shaped telangiectasias on dermoscopy consistent with a dermal nevus. She has several others of these on her back.
On the left plantar foot, seen is a 4 mm verrucous papule consistent with a verruca. Palms and soles are otherwise clear. No appreciated lymphadenopathy in the cervical, supraclavicular lymph node groups. Left infraorbital region seen with well-healed scar from previous squamous cell carcinoma excision.
ASSESSMENT AND PLAN:
1. History of multiple nonmelanoma skin cancers, no evidence of recurrence.
2. History of actinic keratoses appreciated on exam today.
3. Multiple benign lesions, including seborrheic keratoses and verruca likely on the left plantar foot. One irritated seborrheic keratosis on the left neck was treated with cryotherapy x2 cycles. Blistering and wound care discussed with the patient.
4. We will have the patient return to clinic in six months or sooner with any new symptomatic or concerning skin lesions.
