www.Online-Medical-Transcription-Course.com

DERMATOLOGY CONSULTATION

HISTORY: This is a 46-year-old white female with a mole on her back, which has been changing colors lately. She has few other moles as well. She has no significant past medical history. She is on no medications by mouth and has no allergies to medicine. Review of systems is negative. There is no family history of skin cancer. 

PHYSICAL EXAMINATION: On her right mid back, there is a 7.0-mm brown macule, which has a very slightly, irregular pigment pattern. She has a few other smaller evenly pigmented brown papules on her upper back. 

IMPRESSION: Nevi and warts.

RECOMMENDATION: All risks and options were explained. Shave biopsy was declined for the lesion on the right mid back. Features of skin cancer recognition were reviewed. She will see the surgeon for removal of this lesion as a precaution. The wart was treated with liquid nitrogen.