XL skin check template

Verbally consented to the use of AI for note-taking. **Reason for Visit** Patient presented for a routine full-body skin check, expressing a general concern about sun exposure history and a desire for proactive skin cancer surveillance. No specific new lesions of concern were identified by the patient prior to examination. **Other Medical Issues Discussed** Patient inquired about management of seasonal allergies, specifically hay fever, and was advised on over-the-counter antihistamines. Discussion also touched on mild osteoarthritis in the left knee, for which the patient uses paracetamol as needed. **History** 1. General skin health: Patient reports generally good skin health with no significant dermatological issues in the past, apart from occasional dry skin in winter. No history of chronic skin conditions like psoriasis or eczema. No recent illnesses or events affecting skin. **Medical History** * Hypertension, well-controlled with medication. * Mild osteoarthritis, left knee. * No pacemaker in situ. * No history of diabetes, heart disease, or respiratory conditions. **Skin Cancer History** * Excision of a basal cell carcinoma (BCC) on the right forearm in 2010. Lesion was histologically confirmed as a superficial BCC with clear margins. * No other reported skin cancers. **Skin Type Phototype** Fitzpatrick skin type 2 – patient reports burning easily and tanning poorly, consistent with fair skin. **Past UV Exposure and Social History** Patient has a history of significant recreational sun exposure during childhood and young adulthood, including several episodes of severe sunburn with peeling skin. Reports occasional use of solariums in their 20s (estimated 5-7 times). Current occupation is office-based with minimal outdoor exposure. Patient has an outdoor hobby of gardening for approximately 2-3 hours per week, during which they generally wear a hat and long sleeves, but sometimes forgets sunscreen on exposed areas. No exposure to arsenic or dyes. No history of immunocompromise, autoimmune disease, immunosuppressive drugs, chemotherapy, or bone marrow transplant. Generally adheres to sun-smart measures but acknowledges inconsistent sunscreen use. **Medications** * Ramipril 5mg daily for hypertension. * Paracetamol 500mg as needed for pain. * No anticoagulant medications. * No herbal supplements reported. **Allergies** No known drug allergies. Reports mild seasonal allergies to pollen. **Family History** Mother had a melanoma diagnosed at age 65, excised with good prognosis. Father had multiple basal cell carcinomas removed over his lifetime. No other family history of skin cancer or relevant conditions reported. **Physical Examination, Assessment and Plan for Each Skin Lesion** "All lesions were examined with a dermatoscope." "Patient was asked if there are any specific lesions they were worried about under their undergarments and given the opportunity for me to examine them if there was a concern." "Photographs of the lesions were taken with patient consent." Lesion 1: Upper back, approximately 0.5cm, pigmented, symmetrical, not raised. Dermoscopy revealed a regular pigment network with no white clues, polymorphous vessels, arborising vessels, ulceration, peripheral black dots or blots, eccentric structureless area, blue or grey structures, thick lines, radial lines or pseudopods, white lines, parallel ridge pattern, or erythematous pseudonetwork. - Benign junctional naevus. - No action required, monitor for changes. Advised patient on self-monitoring. Lesion 2: Left forearm, approximately 0.3cm, red, slightly raised, non-pigmented. Dermoscopy showed a clear central area with peripheral fine vessels consistent with a dermal naevus. - Benign dermal naevus. - No action required, monitor for changes. Lesion 3: Right cheek, approximately 0.2cm, slightly raised, skin-coloured. Dermoscopy showed multiple small milia-like cysts and comedo-like openings, characteristic of a seborrhoeic keratosis. - Benign seborrhoeic keratosis. - No action required. Patient reassured. **Plan** * Full body skin examination performed with no suspicious lesions identified for immediate biopsy or excision. * Educate patient on ongoing self-surveillance and sun protection. * Advise on regular follow-up for skin checks given personal and family history. **Patient Education** Patient educated on the importance of regular self-skin checks, performing these monthly. Advised on protective measures against sun exposure, including seeking shade, wearing protective clothing, and using broad-spectrum SPF50+ sunscreen daily, especially when outdoors. Discussed warning signs of skin cancer, including changes in size, shape, colour, or texture of existing moles, or any new, unusual growths. Noted that there is no specific recommendation from the health board on how often to have a skin check, but given their history, a 12-month follow-up is recommended. **Clinician's Notes** Patient was cooperative and engaged during the consultation. Understands the importance of ongoing surveillance. Good rapport established.