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Dermatology Transcribed Medical Transcription Sample Report

DATE OF VISIT:  MM/DD/YYYY

CHIEF COMPLAINT:  Worrisome lesion on the right leg.

HISTORY OF PRESENT ILLNESS:  The patient is a well-appearing (XX)-year-old female new to Dermatology.  She comes today at the request of Dr. Doe.  The patient states that her primary care physician noted a lesion on her right medial tibia that had been present for some time, but otherwise asymptomatic.  Otherwise, she feels generally well today and has no additional skin concerns. 

ALLERGIES TO MEDICATIONS:  None.

CURRENT MEDICATIONS:  Warfarin, atenolol, Diovan, furosemide, Klor-Con and glyburide.

PAST MEDICAL HISTORY:
1.  Diabetes.
2.  Hemochromatosis.
3.  Hypertension.

Negative for melanoma.  Positive for skin cancer on the right hand, 3rd finger, dorsal surface that was excised approximately 5 or 6 years ago.

FAMILY MEDICAL HISTORY:  Positive for a spouse who has had skin cancer and allergies in a daughter who has eczema, negative for melanoma.

Pain on the scale of 1 to 10:  The patient rates pain at a level of 7 or 8 when standing on her ankle.  Her primary care physician Dr. Doe is aware of this problem and she has an upcoming appointment to address this issue.

PERSONAL SAFETY:  Negative.

REVIEW OF SYSTEMS:  Updated and reviewed, placed in the chart.

PERTINENT FINDINGS:
1.  Right medial anterior tibia, an 8.5 mm red, erythematous, rough plaque with gritty scale.
2.  On the right upper back, solitary erythematous macule with hyperkeratotic protuberant rough scale.
3.  Right upper lateral arm, 4.5 mm erythematous plaque with scale.
4.  Multiple white, rough, gritty papules on the lower extremities.
5.  On the bilateral forearms and dorsal surface of the hands, multiple erythematous macules with gritty scale.
6.  Multiple coalescing ephelides and lentigines on all sun exposed surfaces.

ASSESSMENT:
1.  Neoplasm of uncertain behavior.  Hypertrophic actinic keratoses versus squamous cell carcinoma on the right upper back and right upper arm.  Hypertrophic actinic keratosis versus squamous cell carcinoma versus inflamed seborrheic keratosis on the right medial tibia. 
2.  Stucco keratoses and seborrheic keratoses.  
3.  Actinic keratosis on the forearms and dorsal surface of the hands.
4.  Actinic damage.

PLAN:  Regarding the 3 neoplasms of uncertain behavior, after the patient identified her name, date of birth, site and procedure , an appropriate time-out was taken.  Written consent was obtained.  Plain lidocaine was injected into each of the 3 sites and a shave biopsy utilizing a DermaBlade with Drysol solution for hemostasis was employed x3.  The patient received appropriate topical wound care and the 3 biopsies were sent to pathology.  Regarding her stucco and seborrheic keratoses, she was reassured of the benign findings.  For her actinic keratoses on the forearms and dorsal hands, liquid nitrogen was applied x12.  For her actinic damage, photo precautions were encouraged.  Skin self-examination was reviewed.