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.
[Patient name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) 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)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
* [Dates of most recent diagnoses of skin cancers, including Breslow thickness or Clark level if provided] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
* [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] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
* [Patient concern regarding specific lesions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Examination:
* FSE down to underwear under appropriate lighting.
* [Fitzpatrick skin type] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
* [Objective findings from full skin check, including any noted lesions or sites if explicitly mentioned] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
* Lesions of concern:
1. [Description and site of first lesion of concern] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
2. [Description and site of second lesion of concern] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
3. [Additional lesions of concern with description and site] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(Use as many numbered bullet points as needed.)
Plan:
* [Management plan including biopsy, excision, or monitoring recommendations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
* [Preventative measures or counselling discussed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
* [Follow-up instructions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)