New Outpatient Consultation
History
Chief Complaint: Mr. Sunshine is seen at the request of Dr. PCP for evaluation of right cheek melanoma.
History of Present Illness: Mr. Sunshine states that the pigmented lesion on his right cheek has been present now for several years, however, over the past few months has become darkened with increasing pigment and occasionally weeps. A recent punch biopsy revealed solar damaged skin with melanoma in situ. He has a second pigmented lesion on his left check that has not changed recently in pigmentation.
Review of Systems: The patient has had one previous episode of skin cancer on his posterior neck. He is uncertain of the exact diagnosis but thought it was likely a squamous cell carcinoma.
Past Medical History: Otherwise negative.
Past Surgical History: He had a left wrist fracture repair.
Allergies: Penicillin.
Medications: None.
Social History: He does not smoke and occasionally drinks alcohol and runs a brewery in Beer Country.
Family History: Noncontributory.
CC: _____________________________
HPI: _____________________________
ROS: _____________________________
PMHx, PFHx, PSHx: _____________________________
Level of History: _______________________
Physical Exam
There is an irregular, darkly pigmented lesion on the central portion of the right maxilla. The maximum length of this lesion is 22 mm and the width is 12 mm. It is irregularly shaped and multicentric, with a single satellite, darkly pigmented lesion at the superolateral border. A separate, more lightly pigmented lesion measuring approximately 10 x 12 mm is present in the central portion of the left cheek.
What level exam is documented? __________________________
Medical Decision Making Data
Pathology report reveals melanoma in situ of the right cheek with a separate pigmented lesion of the left cheek.
Impression: I would recommend that the patient undergo wide local excision although tighter margins can be observed on the left side compared to the right. Local reconstruction with adjacent tissue transfer technique is planned in order to prevent postoperative ectropium. The patient is in agreement with this. This will be scheduled within the next week at Greatsuninthesky Hospital.
cc: Dr. PCP
Data: ______________
Diagnosis: ______________
Risk: ______________
Complexity of Medical Decision Making: __________________
Put It All Together
History ________________
Exam ________________
Medical Decision Making ________________
Code Documented ________________