Bernadette10
Guru
Dermatology clinic visit. Patient was seen for a cheek lesion that was biopsied at this visit that came back as SCC. I was thinking low MDM since the diagnoses are acute, uncomplicated problems, no data, and moderate risk for the prescription medication. Or would the cheek lesion be moderate problem complexity since it was a new problem with uncertain prognosis before it was biopsied, which would give moderate MDM?
Here today for an evaluation of a lesion. Her symptoms onset 2 months ago and are located to the left cheek. She describes the symptoms as mild pain. She denies any previous treatment to the area. Patient denies a personal history of non-melanoma skin cancer and melanoma. Patient denies a family history of non-melanoma skin cancer and melanoma. She has a history of blistering sunburns at a younger age.
Head/Scalp/Face: Clean, dry, and intact. Erythematous, scaly patch x3 (AK) Greasy, scaly patches to the bilateral ears and hairline. subcutaneous nodule with puncta to the left upper cheek. Hyperkeratotic, erythematous nodule to the left lower cheek (1/1) – picture taken today.
Neck: Clean, dry, and intact.
Chest/Axillae/Breast: Clean, dry, and intact.
Abdomen: Clean, dry, and intact.
Back: Clean, dry, and intact.
Right Upper Extremity: Clean, dry, and intact.
Left Upper Extremity: Clean, dry, and intact.
Right Lower Extremity: Clean, dry, and intact.
Left Lower Extremity: Clean, dry, and intact.
Groin/Buttocks/Genitalia: Clean, dry, and intact.
Digit/Nails: Clean, dry, and intact.
Eccrine/apocrine glands: Clean, dry, and intact.
Lips/Gums/Teeth: Clean, dry, and intact.
Conjunctiva/ Eyelids: Clean, dry, and intact.
Neoplasm of LT cheek: Risk, benefit, and alternatives were discussed with the patient and the patient agreed to the procedure. The area was cleaned with alcohol. 1 cc of lidocaine 1% with epinephrine was used for local anesthesia. A sharp derma blade was used to remove part or all of the lesion. The specimen was sent for pathology. Hemostasis was obtained with aluminum chloride and or monopolar hyfrecation. The area was then dressed and bandaged. Patient tolerated the procedure well without adverse events.
1. Actinic skin damage
2. Seborrheic keratosis ketoconazole (NIZORAL) 2 % cream
3. Actinic keratosis
4. Neoplasm of uncertain behavior of skin Specimen to pathology which showed SCC of LT cheek
5. Seborrheic dermatitis
Here today for an evaluation of a lesion. Her symptoms onset 2 months ago and are located to the left cheek. She describes the symptoms as mild pain. She denies any previous treatment to the area. Patient denies a personal history of non-melanoma skin cancer and melanoma. Patient denies a family history of non-melanoma skin cancer and melanoma. She has a history of blistering sunburns at a younger age.
Head/Scalp/Face: Clean, dry, and intact. Erythematous, scaly patch x3 (AK) Greasy, scaly patches to the bilateral ears and hairline. subcutaneous nodule with puncta to the left upper cheek. Hyperkeratotic, erythematous nodule to the left lower cheek (1/1) – picture taken today.
Neck: Clean, dry, and intact.
Chest/Axillae/Breast: Clean, dry, and intact.
Abdomen: Clean, dry, and intact.
Back: Clean, dry, and intact.
Right Upper Extremity: Clean, dry, and intact.
Left Upper Extremity: Clean, dry, and intact.
Right Lower Extremity: Clean, dry, and intact.
Left Lower Extremity: Clean, dry, and intact.
Groin/Buttocks/Genitalia: Clean, dry, and intact.
Digit/Nails: Clean, dry, and intact.
Eccrine/apocrine glands: Clean, dry, and intact.
Lips/Gums/Teeth: Clean, dry, and intact.
Conjunctiva/ Eyelids: Clean, dry, and intact.
Neoplasm of LT cheek: Risk, benefit, and alternatives were discussed with the patient and the patient agreed to the procedure. The area was cleaned with alcohol. 1 cc of lidocaine 1% with epinephrine was used for local anesthesia. A sharp derma blade was used to remove part or all of the lesion. The specimen was sent for pathology. Hemostasis was obtained with aluminum chloride and or monopolar hyfrecation. The area was then dressed and bandaged. Patient tolerated the procedure well without adverse events.
1. Actinic skin damage
2. Seborrheic keratosis ketoconazole (NIZORAL) 2 % cream
3. Actinic keratosis
4. Neoplasm of uncertain behavior of skin Specimen to pathology which showed SCC of LT cheek
5. Seborrheic dermatitis