CHIEF COMPLAINT: Annual skin checkup.
HISTORY OF PRESENT ILLNESS: The patient is now approaching 4 years post excision of a Clark level II, Breslow level 0.46 mm melanoma from her mid back area. She is also now about a year and a quarter post Mohs surgery for basal cell carcinoma of the right medial canthus. The scar on that latter area was somewhat thickened, and she had a partial repair, but she feels now, she does want to do anything further about it, and she has been having no other problems with either one of the sites. Certainly, nothing seems to be coming back in either site. She has no other specific skin complaints today.
PAST MEDICAL HISTORY: As above.
CURRENT MEDICATIONS: Hydrochlorothiazide.
ALLERGIES: No known allergies to medications.
REVIEW OF SYSTEMS: The following issues were identified; hypertension, arthritis, kidney, bladder trouble.
FAMILY HISTORY: The patient is not sure about her family history at all.
SOCIAL HISTORY: The patient does routinely wear a sunscreen, and pain assessment is negative.
PHYSICAL EXAMINATION: The patient is a tall, thin woman who does not appear to be in any acute distress. The patient is well developed and well nourished in appearance. She is oriented to person, time, and place. Her mood, affect, and grooming appear normal to me. Full surface skin examination was carried out, including the head area, scalp, ears, nose, lips, tongue, oral mucous membranes, eyebrows, eyelashes, eyelids, and conjunctivae, the rest of the face, the neck, the trunk anterior and posterior, the abdomen, and the upper and lower extremities bilaterally. Genital area not examined.
PERTINENT FINDINGS: Well-healed scar, mid back. No clinical evidence of recurrence. Scar looking perfectly nice to me in the right medial canthus, again no clinical evidence of recurrence. No nodes were palpable in the neck, supraclavicular, axillary, or groin areas. She had scattered seborrheic keratoses on the trunk as well as some angiomas, but no other active or unusual lesions were noted in all areas checked.
IMPRESSION:
1. Melanoma, Clark level II, Breslow level 0.46 mm, 4 years post excision. No clinical evidence of recurrence.
2. Basal cell carcinoma of the right medial canthus. Approximately, one year post Mohs surgery. No clinical evidence of recurrence.
3. Seborrheic keratoses.
4. Angiomas.
PLAN: Reassured her that everything looked good today. There was nothing that we need to do anything about. We did talk about sun precautions and sunscreen use. Follow up in one year.
