CHIEF COMPLAINT: The patient is seen today for a full skin exam.
HISTORY OF PRESENT ILLNESS: We last saw the patient one year ago. At that time, she had multiple actinic keratoses. She has not noticed anything new or changing on her skin since the last visit. The patient occasionally wears sunscreen. She tries to wear a hat when she is outdoors.
PAST MEDICAL HISTORY: No history of skin cancer or melanoma.
PAIN SCORE: None.
PERSONAL SAFETY ISSUES: None.
MEDICATIONS:
1. Aspirin.
2. Omeprazole.
3. Fish oil.
4. Pravastatin.
ALLERGIES: None.
FAMILY HISTORY: No history of skin cancer or melanoma.
SOCIAL HISTORY: She spends a high amount of time outdoors and does not use sunscreen.
REVIEW OF SYSTEMS: Reviewed with her today and documented in her chart.
PHYSICAL EXAMINATION: This is a pleasant woman, skin type II. The patient is awake, alert, and oriented x3, in no acute distress, with normal mood and affect. Skin examination included face, scalp, hair, neck, chest, abdomen, back, arms, legs, hands and feet bilaterally and buttocks. On the right ear lobe, she has a 3 mm pink plaque with gritty scale. The patient has extensive freckling on the back of the neck and forearms. Also, scattered on the trunk and extremities are multiple 3 to 4 mm stuck-on appearing, brown, verrucous plaques. On the left clavicle, she has a pink pearly 2 mm papule.
IMPRESSION AND PLAN:
1. Actinic keratosis x1 on the right ear lobe. After verbal consent was obtained, this was treated today with cryotherapy. Wound care was discussed.
2. Neoplasm of uncertain behavior on the left clavicle, possible basal cell carcinoma. We recommended that we perform a shave biopsy today, but the patient would prefer to monitor the area for changes. The patient will return in three months for re-evaluation.
3. Actinic damage. Reviewed photo precautions and discussed ABCDs of monthly self-skin examination.
4. Seborrheic keratoses. These are benign. The patient was reassured. No treatment required.
FOLLOWUP: The patient should follow up in three months to recheck a possible basal cell carcinoma on the left clavicle and in one year for a full skin exam.
