Full Skin Examination
Current Concerns:
- New mole on left upper back, noticed 3 months ago, with recent increase in size and irregular borders.
- Persistent dry, itchy rash on elbows and knees for 6 months.
- Concern about sun damage on face.
Examination:
- Face: Multiple solar lentigines on cheeks and forehead. Mild erythema on nose and central face. No suspicious lesions noted.
- Ears: Bilateral actinic keratoses on superior helix, left ear larger (4mm). No other significant findings.
- Scalp: Diffuse mild seborrhoeic dermatitis with fine scaling. No alopecia or suspicious lesions.
- Neck: Scattered seborrhoeic keratoses, largest 5mm on posterior neck. No palpable lymphadenopathy.
- Chest: Several benign melanocytic naevi, stable. Mild telangiectasias on décolletage.
- Abdomen: Few scattered benign melanocytic naevi. No rashes or other abnormal findings.
- Upper limbs: Bilateral actinic keratoses on extensor aspects of forearms. Multiple solar lentigines. Dry, erythematous, well-demarcated plaques with silvery scales on bilateral elbows, consistent with psoriasis.
- Hands: Fine wrinkles, multiple solar lentigines. No nail changes or suspicious lesions.
- Lower limbs: Bilateral varicosities on medial calves. Dry, erythematous, well-demarcated plaques with silvery scales on bilateral knees, consistent with psoriasis. No suspicious pigmented lesions.
- Feet: Calluses on heels. No suspicious lesions or nail changes.
- Buttocks: No lesions, rashes, or other abnormal findings.
- Back: Asymmetrical, irregularly bordered pigmented lesion on left upper back, approximately 8mm in diameter, mixed shades of brown and black. Several benign melanocytic naevi.
Plan:
- Excisional biopsy of suspicious lesion on left upper back for histopathology.
- Prescribe topical corticosteroid cream (betamethasone 0.05%) for psoriasis on elbows and knees, apply twice daily for 2 weeks.
- Recommend daily broad-spectrum sunscreen use (SPF 50+) and sun-protective measures.
- Schedule follow-up in 4 weeks to review biopsy results and assess psoriasis treatment response.
- Patient education provided on ABCDEs of melanoma and importance of self-skin checks.
Billing:
- ICD-10 codes: D22.5 (Melanocytic naevi of trunk), L40.0 (Psoriasis vulgaris), L57.0 (Actinic keratosis), Z12.83 (Encounter for screening for melanoma)
