Case Study: Patient with Skin Lesion
Case Study: Patient with Skin Lesion
Case Study: Patient with Skin Lesion
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NEXT OF KIN George Thompson RELATION TO PATIENT Spouse PHONE 5555555555 ADDRESS –
PATIENT’S MOTHER’S MAIDEN NAME
Holske
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Subjective
Sixty-year-old female patient presents with a lesion that doesn’t heal on her left shoulder. She describes the lesion as a mole that became itchy and has been getting a darker pigment over time. She states that she first thought it was a “bug bite” that she had been scratching, but the lesion has been present for 4 weeks without healing. No rashes or other skin complaints.
Objective
Patient’s blood pressure is 128/76. Patient’s HR is 78 bpm and regular. Full skin examination reveals several erythematous macules scattered evenly on face and shoulders. Three black, symmetric, well-demarcated papules are present on the upper back measuring 6mm-1cm.
Encounter – Office Visit Date of service: 04/05/17 Patient: Virgi… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
1 of 2 4/5/17, 4:58 PM
Lesion of concern to the patient is located on the left anterolateral shoulder, 2 cm inferior to the acromioclavicular joint. It measures 7 mm in diameter and has an asymmetrical, black/brown/red appearance.
Assessment
Multiple benign nevi found the face, trunk, and upper extremities. Multiple benign papules present across upper back. Left shoulder lesion shows indications of melanoma.
DDX: D03.60 Melanoma in situ of unspecified upper limb, including shoulder. C43.60 Malignant melanoma of unspecified upper limb, including shoulder. D03.62 Melanoma in situ of left upper limb, including shoulder.
Plan
Patient will be referred to dermatologist for biopsy of left shoulder lesion. Patient is advised to continue use of sunscreen when outdoors. Follow-up appointments will be scheduled to monitor benign nevi and papules for any suspicious changes.
Free cloud based EHR
Encounter – Office Visit Date of service: 04/05/17 Patient: Virgi… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
2 of 2 4/5/17, 4:58 PM
Module 02 Course Project: Clinical Notes
Each question is associated with the clinical notes provided. Refer to these when answering each question. Please type your answer in the “Click here to enter text” space.
Patient A – Kay June Salisbury
Kay is complaining of lower back pain. What is the medical term used to describe the lower back?
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In the subjective and plan sections of this SOAP note, the abbreviation OTC is used. What does this mean?
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In the objective section of this SOAP note, the doctor noted that the patient has limited flexion in the lumbar spine. Describe what means to “flex” the spine.
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If Kay had also mentioned during this visit that she has been experiencing neck pain, which medical term could be used to describe this complaint? (Use the appropriate suffix for pain)
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The abbreviation ROM is used twice in this SOAP note. What does ROM mean in this context?
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Kay’s physical exam revealed hypertrophy of her muscles. Describe what this means. What is the abnormality present?
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In the assessment section of this document, the abbreviation DDX is used. This is a very commonly used abbreviation. What does DDX stand for?
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The doctor has determined that Kay may have radiculopathy. Describe what this word means in a way that an average patient could understand.
The word “unilateral” is used to describe the possible disk herniation. What does unilateral mean?
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Find an image of a “vertebral disk herniation.” Describe (in your own words) what is happening to the anatomical structures of the spine.
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In the plan section of this SOAP note, the patient is being referred for lumbar and sacroiliac radiography. What does this mean? Define each word: lumbar, sacroiliac, and radiography.
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This patient may need a follow-up MRI. What does this abbreviation stand for?
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