Dermatologist New Patient

Reason for Appointment: 1. Patient reports a new, rapidly growing mole on their upper back, which has recently become itchy. They are concerned about potential malignancy due to a family history of melanoma. The mole has been present for approximately 3 months and has doubled in size in the last month. History of Present Illness: Ms. Jane Doe, a 45-year-old female, presents with a chief complaint of a changing mole on her upper back. She first noticed the lesion approximately 3 months ago, describing it as a small, flat brown spot. Over the past month, it has significantly enlarged and changed in colour, now appearing irregularly pigmented with areas of darker brown and black. Concurrently, she has experienced intermittent itching at the site, which is worse at night. She has not attempted any treatments for the mole. She denies any trauma to the area or recent sun exposure history beyond her usual activities. There is no associated pain, bleeding, or discharge. She reports no similar lesions in the past. She is a keen gardener and spends a fair amount of time outdoors. Current Medications: * Atorvastatin 20 mg, oral, once daily, takes regularly. * Levothyroxine 75 mcg, oral, once daily, takes regularly. "Medication list reviewed and reconciled with the patient." Active Problem List: 1. Suspicious pigmented lesion, upper back 2. Hypercholesterolemia 3. Hypothyroidism Past Medical History: Patient has a history of hypercholesterolemia diagnosed 5 years ago and hypothyroidism diagnosed 10 years ago, both well-controlled with current medications. No history of previous skin cancers or significant dermatological conditions. Family History: Patient's mother was diagnosed with melanoma at age 60. Social History: Patient is a non-smoker, rarely consumes alcohol, and is actively involved in gardening, which involves regular sun exposure. Allergies: Penicillin (hives) Vital Signs: BP 128/78 mmHg, HR 72 bpm, RR 16 bpm, Temp 36.8°C, O2 Sat 98% on room air, Ht 165 cm, Wt 70 kg. Examination: Skin Exam: Patient is a well-nourished, alert, and oriented female in no acute distress. General skin examination reveals fair skin with numerous scattered benign nevi, consistent with Fitzpatrick skin type II. On the upper back, approximately 3 cm inferior to the C7 spinous process, there is an irregularly shaped, multi-pigmented lesion measuring approximately 8x6 mm. The lesion exhibits asymmetrical borders, a varied colour profile including shades of tan, brown, and black, and has an uneven surface. No ulceration, crusting, or bleeding noted. No palpable regional lymphadenopathy. Remaining skin exam is unremarkable for suspicious lesions or rashes. Assessments: 1. Atypical melanocytic nevus, upper back (R21.0) 2. Concern for melanoma Treatment: 1. Atypical melanocytic nevus, upper back; Concern for melanoma Prescribed: Surgical excision of the suspicious lesion with a 2 mm margin. Sent prescription for Lidocaine 1% with Epinephrine 1:100,000 for local anaesthesia. Instructions given to prepare for an in-office procedure, including avoiding blood thinners as advised. Advised patient on strict wound care instructions post-excision and to monitor for any signs of infection or excessive bleeding. Counseled on sun protection measures, including daily use of broad-spectrum sunscreen with SPF 30+, wearing protective clothing, and seeking shade during peak UV hours. Follow-Up: Follow-up appointment scheduled for 1 November 2024, in 2 weeks for wound check and biopsy results.