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)
Full Skin Examination
Current Concerns:
- [list current concerns, one concern per line] (Include only if explicitly mentioned in the transcript, contextual notes, or clinical note.)
Examination:
- Face: [describe any lesions, pigmentation changes, rashes, or abnormal findings on the face] (Include only if findings are explicitly mentioned in the transcript, contextual notes, or clinical note.)
- Ears: [describe any lesions, pigmentation changes, rashes, or abnormal findings on the ears] (Include only if findings are explicitly mentioned.)
- Scalp: [describe any lesions, scaling, rashes, alopecia, or other abnormalities of the scalp] (Include only if findings are explicitly mentioned.)
- Neck: [describe any lesions, pigmentation changes, lumps, rashes, or other abnormal findings on the neck] (Include only if findings are explicitly mentioned.)
- Chest: [describe any lesions, rashes, pigmentation changes, or abnormal findings on the chest] (Include only if findings are explicitly mentioned.)
- Abdomen: [describe any lesions, rashes, striae, or other abnormal findings on the abdomen] (Include only if findings are explicitly mentioned.)
- Upper limbs: [describe any lesions, pigmentation changes, rashes, or abnormal findings on the upper limbs] (Include only if findings are explicitly mentioned.)
- Hands: [describe any lesions, rashes, nail changes, or other abnormal findings on the hands] (Include only if findings are explicitly mentioned.)
- Lower limbs: [describe any lesions, pigmentation changes, varicosities, or abnormal findings on the lower limbs] (Include only if findings are explicitly mentioned.)
- Feet: [describe any lesions, rashes, nail changes, or other abnormal findings on the feet] (Include only if findings are explicitly mentioned.)
- Buttocks: [describe any lesions, rashes, or other abnormal findings on the buttocks] (Include only if findings are explicitly mentioned.)
- Back: [describe any lesions, rashes, pigmentation changes, or other abnormal findings on the back] (Include only if findings are explicitly mentioned.)
Plan:
- [outline the plan, one line per point] (Include all relevant interventions, recommendations, and follow-up details explicitly mentioned in the transcript, contextual notes, or clinical note.)
Billing:
- [include ICD-10 codes as applicable] (Add codes relevant to diagnosis and plan only if explicitly mentioned in the transcript, contextual notes, or clinical note.)
(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 to include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, leave the relevant placeholder or section blank.)