SUBJECTIVE: The patient is a well-appearing (XX)-year-old Hispanic female last seen in Dermatology. At the last visit, she reported a worrisome lesion on her right medial tibia that had failed to resolve.
Physical examination disclosed an 8 mm, red, erythematous, rough plaque with gritty scale. Incidental findings included a 4 mm erythematous plaque with scale on the right upper lateral arm and a solitary erythematous macule with hyperkeratotic rough scale on the right upper back. All 3 lesions were given shave biopsies.
The patient reports that, for the most part, the biopsy sites are well healed. The one on her back was difficult for her to reach, and she had no assistance with wound care, so she could not change it frequently, but she believes it is okay. The one on the right lower leg remains tender. She applied bacitracin on a daily basis to the site ever since her last visit, but it has not healed as quickly as the other 2 sites. She feels generally well and has no additional skin concerns.
OBJECTIVE: The patient is a well-nourished, well-developed Hispanic female, photo type 2, in no acute distress. She is alert and oriented x3. She received a full dermatologic exam on MM/DD/YY. Today’s exam was limited to the areas of concern. Located on the right upper arm is a well-healed biopsy site with some hemorrhagic crust. No evidence of infection. Also located on the right upper back is another well-healed biopsy site with some hemorrhagic crust and no evidence of infection. On the right medial anterior tibia is a biopsy site with central erosion that reveals some yellow slough and serous drainage. There was maceration evident from the Band-Aid and chronic application of bacitracin. Also noteworthy is a 4 mm erythematous papule with a central core of erosion on the right forehead.
Pathology states the following: Right medial tibia: Squamous cell carcinoma in situ arising in hypertrophic actinic keratoses. Right upper back: Squamous cell carcinoma arising in actinic keratoses, primarily squamous cell in situ with focus of early invasion. Right upper arm: Actinic keratoses, acantholytic type.
ASSESSMENT: Two newly diagnosed squamous cell carcinomas in situ. The one on the right upper back has a focus of early invasion and the one on the right medial tibia shows evidence of contact dermatitis due to the Band-Aid and application of bacitracin. Also biopsy-proven actinic keratoses on the right upper arm. Neoplasm of uncertain behavior on the right forehead.
PLAN: Regarding the squamous cell carcinoma in situ on the right medial tibia, treatment will be deferred until the lesion is healed. Regarding the right upper back, the squamous cell carcinoma does have a focus of early invasion, and it is very difficult for the patient to assist with wound care. She will be referred for dermatology surgery for an excision at that site and most likely will also receive an excision for the area on the right medial tibia at the same time provided it has healed from the contact dermatitis. For the actinic keratosis on the right upper arm, it was treated with liquid nitrogen with good effect. The patient will return to Dermatology in 1 month to assess whether the contact dermatitis has resolved on the right medial tibia. In the meantime, the appointment coordinator will contact the patient regarding a procedure date for her excisions.
Regarding the neoplasm of uncertain behavior on the right forehead, the patient was instructed to continue to monitor the site. If it has not resolved at next visit, biopsy will be considered. Followup appointment scheduled for 1 month in Dermatology.
