CHIEF COMPLAINT: Squamous cell carcinoma on the right side of the face.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman who is sent over by Dr. (XX) because of biopsied large skin lesion on the right side of his face that was positive for squamous cell carcinoma. He was sent over for a possible excision. The patient says he has had this lesion for years but it has been getting bigger and now starting to bother him a little bit, and at times, he scratches it and it bleeds. He is also currently complaining of bleeding from his mouth. He does have a long history of having basal cell skin cancer excised per Dr. (XY) as well as squamous cell carcinomas excised from skin going back many, many years. Recently, he has also had a benign hyperplastic mucosal lesion excised from his tongue by Dr. (YY). Otherwise, he has no other present complaints and is fairly comfortable sitting in his wheelchair.
PAST MEDICAL HISTORY: Significant for left hip surgery. Again, as noted above in history of present illness, skin cancers and tongue lesion. He has benign prostatic hypertrophy, gastroesophageal reflux disease, chronic atrial fibrillation with chronic anticoagulation, hyperthyroidism, and osteoarthritis.
CURRENT MEDICATIONS: Coumadin 3.5 mg daily, Celexa 40 mg daily, atenolol 25 mg twice daily, indomethacin 50 mg daily, Zyprexa 2.5 mg daily, diltiazem 120 mg daily, omeprazole 20 mg by mouth daily, several stool softeners, Tylenol, and things to help with moving his bowels.
ALLERGIES: He has no known medical allergies.
SOCIAL HISTORY: Negative for smoking or drinking.
PAST SURGICAL HISTORY: He has had an operation of his prostate three times; I believe these were all TURPs.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Currently denies any problems with his ear, nose, or throat. Denies any cardiovascular, respiratory, GI, and his only GU complaint is difficulty, and he is complaining of some blood coming out of his mouth just this morning. This happens once in a while but recently this has been happening more as evident this morning.
PHYSICAL EXAMINATION:
GENERAL: On exam, this is a (XX)-year-old gentleman who looks his stated age, in no acute distress.
HEENT: First of all, he is noted to have multiple skin lesions and moles throughout his entire head, face, neck, and body. One is directly on mandibular line of his right cheek that measures 3.2 cm in greatest dimension. It is elevated about 2 cm and is a fairly ugly looking carcinomatous lesion. Examination of his mouth reveals two, just less than 1 cm lesions on the buccal mucosa on the left side that are actively oozing a little bit of blood, very little. He also has a slight deformity of his tongue. Poor dentition is also appreciated.
NECK: No cervical or clavicular adenopathy. Trachea is midline.
LUNGS: Clear but distant breath sounds.
HEART: Irregular rate and rhythm.
ABDOMEN: Soft and nontender.
EXTREMITIES: Have 1+ edema in the lower extremities with multiple skin lesions. No major joint deformity.
NEUROLOGIC: He is actually alert and oriented x3. His sensory and motor functions were screened and are intact.
IMPRESSION AND PLAN:
- The patient has a large 3.2 cm squamous cell carcinoma on the right side of his face that is going to need to be excised. It has bled at times when he scratches it and hits it and it is fairly large and he is requesting excision.
- Two lesions on the buccal mucosa on the left side, inside of his mouth. I am not sure what these represent, but probably we need to excise these as well and evaluated by ENT doctor. We therefore have made arrangements for him to see Dr. (YX) on Monday. We are tentatively planning his surgery on Wednesday. Hopefully, Dr. (YX) can deal with his lesions in his mouth at that time and we will with the large skin lesion on the right side of his face. We went over the risks and benefits with him and he has agreed to proceed.
