Dermatologist's note (custom)

Diagnosis: 1. Actinic Keratosis - Assessment, likely diagnosis for Issue 1: Actinic Keratosis - Differential diagnosis for Issue 1: Squamous cell carcinoma in situ - Treatment for Issue 1: Cryotherapy Treatment: Cryotherapy to multiple actinic keratoses on the face. Follow-up: Review in 3 months. Investigations: Biopsy of suspicious lesion. Investigations with results: 01/11/2024, Biopsy results: Actinic Keratosis. Past Skin History: 01/01/2020, Treatment for basal cell carcinoma. Past Medical History: 2018, Hypertension. Medication: Amlodipine 5mg daily. Allergies: No known allergies. Family History: Mother with melanoma. Social History: Frequent sun exposure, uses sunscreen inconsistently. I reviewed the above 62 year old gentleman. My clinical notes from today are as follows: Subjective: Patient presents with multiple scaly lesions on the face, which have been present for several months. The lesions are asymptomatic but have been increasing in number. Patient reports a history of significant sun exposure over their lifetime. No previous treatment. Objective: Vitals: BP 130/80, HR 72. Physical examination findings: Multiple erythematous, scaly papules and plaques on the face, consistent with actinic keratoses. Dermoscopy revealed atypical vessels in some lesions. Assessment: 1. Actinic Keratosis, diagnosed based on clinical presentation and dermoscopy findings. Treatment plan includes cryotherapy. Management Plan as above: Cryotherapy to multiple actinic keratoses. Additional Notes: Patient educated on the importance of sun protection and regular skin self-examination. Next Steps: Follow-up appointment in 3 months to assess response to treatment and monitor for new lesions. I would recommend www.bad.org.uk and dermnetnz.org for information on the above.