PROBLEM: Actinic keratosis.
SUBJECTIVE: The patient has had a biopsy from her left nose, which showed actinic keratosis. The lesion, however, continues to recur. She was being treated with liquid nitrogen in the past. She has also noted a rough area below her left lower lip.
OBJECTIVE: She has a small rough scaly macule on the left side of the nose and other on the left lower lip. The area on the nose is just above the biopsy site.
ASSESSMENT: Actinic keratosis.
PLAN:
1. Recommended to treat with light Efudex cream twice daily for 3 weeks on both lesions.
2. Asked to call me if lesion recurs.
3. She was warned about hypopigmentation.
Sample #2
SUBJECTIVE: The patient is an (XX)-year-old woman who comes for followup of basal cell carcinoma to left thigh treated in January (XXXX). She has noted a rough area on the left nose but no other skin, hair, nail complaints. She did have a small stroke in July from which she has recovered.
OBJECTIVE: Full exam done. She has a well-healed scar on the left thigh. Her skin is clear. No lesions appreciated with the exception of a rough scaly papule on the left nose. She has scattered seborrheic keratosis also.
ASSESSMENT:
1. Actinic keratosis, left nose. This is treated with liquid nitrogen spray.
2. History of basal cell carcinoma left thigh, January (XXXX).
PLAN:
1. She will return in one year’s time.
2. Lesion will be also treated with cryosurgery.
Sample #3
This is a (XX)-year-old gentleman with a history of squamous cell carcinoma on his lip a year ago who returns for a skin exam. No lesions on his skin he is concerned about. He denies itching, pain or bleeding at any skin lesion.
MEDICATIONS: Atenolol, lisinopril, and hydrochlorothiazide.
ALLERGIES: NONE KNOWN.
Review of systems, social history, family history is being updated per the patient information sheet placed in his medical record.
OBJECTIVE: On examination of the face, neck, chest, abdomen, back, upper and lower extremities, hands and feet bilaterally, there are rough keratotic 2-4 mm macules on both cheeks in 4 locations altogether. The rest of the skin exam is unremarkable.
ASSESSMENT: Actinic keratoses.
PLAN: Liquid nitrogen, 10 seconds, for destruction of actinic keratoses. Continue sun screen. She is to followup in 1 year.
