REASON FOR VISIT: Skin lesion, left upper arm.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who suffers from cirrhosis but otherwise has been doing well and has noticed a skin lesion on her left shoulder and upper arm area. It is a scaling type lesion. She states that it is very itchy. She keeps scratching and it has even bled in the past. She was referred for evaluation. She has no history of any skin cancers in the past.
PAST MEDICAL HISTORY: Her past medical history is significant for cirrhosis. She also has gastroesophageal reflux disease and a seizure disorder.
MEDICATIONS: Current medications include spironolactone 100 mg a day, furosemide 20 mg a day, vitamin K daily, propranolol 80 mg a day, Nexium 40 mg a day, baby aspirin a day, multiple vitamin a day, Keppra 500 mg twice a day and potassium, she takes, once a day.
ALLERGIES: Allergies are to TETANUS IMMUNIZATION.
SOCIAL HISTORY: Negative for smoking and drinking now, but she used to drink heavily.
FAMILY HISTORY: Her family history is significant for peripheral vascular disease, but no history of cirrhosis in the family.
REVIEW OF SYSTEMS: Reviewed for 9 systems and was negative.
PHYSICAL EXAMINATION: On exam, this is a (XX)-year-old female who looks her stated age, in no acute distress. Her neck has no cervical, clavicular, and there is no axillary adenopathy. Trachea is midline. No jugular venous distention. Her lungs were clear and her heart has a regular rate and rhythm. Abdomen is soft and nontender. No pitting edema in her extremities. She does have a skin lesion on her left shoulder, which measures approximately 0.4 cm x 0.3 cm. It is slightly irregular and raised and scaling. Neurologically, she is alert and oriented. Sensorimotor function was screened and intact.
IMPRESSION: The patient has a suspicious lesion on her left upper arm.
RECOMMENDATIONS: Recommendation is for shave biopsy. She agreed. Xylocaine 1% was used for local after Betadine prep. The lesion was shaved off using scalpel and cautery used to control little bleeding. The specimen was sent to pathology. She will return if there are any problems, and we will give her followup on pathology when it is available.
