Eleanor Vance consented for medical AI.
Presenting for skin check.
History of Presenting Complaint:
* History of previous skin cancers, specifying melanoma versus non-melanoma skin cancers (NMSCs): Patient reports a history of basal cell carcinoma (BCC) diagnosed in 2018.
* Dates of most recent diagnoses of skin cancers, including Breslow thickness or Clark level if provided: BCC diagnosed in 2018, treated with excision. No recurrence.
* Relevant risk factors including childhood sun exposure, occupational exposure, family history of skin cancers, geographical location, relevant hobbies, and current or past sun protection practices: Patient reports significant childhood sun exposure, fair skin, and a family history of skin cancer (mother). Patient uses SPF 30 sunscreen daily.
* Patient concern regarding specific lesions: Patient is concerned about a new mole on her back that has changed in size and colour.
Examination:
* FSE down to underwear under appropriate lighting.
* Fitzpatrick skin type: Type II.
* Objective findings from full skin check, including any noted lesions or sites if explicitly mentioned: Multiple benign nevi noted. One suspicious lesion on the upper back.
* Lesions of concern:
1. Description and site of first lesion of concern: Asymmetrical, irregular borders, and varying shades of brown, measuring 6mm on the upper back.
2. Description and site of second lesion of concern: None.
3. Additional lesions of concern with description and site: None.
Plan:
* Management plan including biopsy, excision, or monitoring recommendations: Biopsy of the suspicious lesion on the upper back.
* Preventative measures or counselling discussed: Discussed sun protection measures, including regular sunscreen use, avoiding peak sun hours, and regular skin self-exams.
* Follow-up instructions: Follow-up in two weeks for biopsy results. Schedule a full skin check in six months.