Clinic Outcome Letter to GP

Dear Dr. Smith I saw Mr. John Doe on 1 November 2024. Below are the details of the issues discussed and the further plan. Current Issues: - Mr. Doe presented with a 3-month history of a persistent lump on his left forearm, approximately 2cm in diameter. He reports it is slowly growing and occasionally tender to touch, particularly after light exertion. No associated discharge, redness, or warmth. No history of trauma to the area. Previous Medical Issues: - Hypertension, diagnosed 5 years ago, well-controlled with medication. - Appendectomy, 20 years ago. Current Medications/Treatments: - Amlodipine 5mg once daily. - Paracetamol as needed for occasional headache. - No known herbal supplements. - Known allergies: Penicillin (rash). - Relevant social history: Non-smoker, occasional alcohol use. Works as an accountant. Lives with his wife and two children. Exercises regularly. Assessment: - Clinical examination revealed a firm, mobile, non-tender subcutaneous nodule on the volar aspect of the left forearm, measuring approximately 2.5 x 2 cm. Overlying skin appeared normal. No regional lymphadenopathy. Differential considerations include lipoma, sebaceous cyst, or less commonly, a soft tissue neoplasm. Discussion held regarding the benign nature of most such lesions and the option for surgical excision for definitive diagnosis and symptomatic relief. Further Plan: - Discussed with Mr. Doe the option for excisional biopsy of the left forearm lump for histological analysis. - Referral arranged for ultrasound imaging of the lump to further characterise the lesion prior to surgery. - Patient advised to monitor for any changes in size, pain, or overlying skin appearance in the interim. - Follow-up appointment scheduled for 3 weeks to discuss ultrasound results and plan for surgical excision. Yours sincerely, Dr. Eleanor Vance, Consultant Plastic & Reconstructive Surgeon