Medical Terminology mod 2 course project

Chief complaint

Skin lesion

PATIENT Virginia T Thompson DOB 02/05/1957 AGE 60 yrs SEX Female PRN MO686770

FACILITY Northstar Physicians Center T (999) 999-9999 1234 Sunshine Way 100 Minneapolis, MN 99999

ENCOUNTER

NOTE TYPE SOAP Note SEEN BY Nazir Ashaad DATE 04/05/2017 AGE AT DOS

60 yrs

Not signed

Patient identifying details and demographics

FIRST NAME Virginia MIDDLE NAME T LAST NAME Thompson SSN -

SEX Female DATE OF BIRTH 02/05/1957 DATE OF DEATH - PRN MO686770

ETHNICITY Not Hispanic or Latino

PREF. LANGUAGE

English

RACE Patient declined to specify

STATUS Active patient

CONTACT INFORMATION

ADDRESS LINE 1 5432 Rebrow St ADDRESS LINE 2 - CITY Lakeside STATE NY ZIP CODE 27511

CONTACT BY Home Phone EMAIL virginiat@testpati

ent.com HOME PHONE (555) 555-5555 MOBILE PHONE (555) 555-5555 OFFICE PHONE - OFFICE EXTENSION

-

FAMILY INFORMATION

NEXT OF KIN George Thompson RELATION TO PATIENT Spouse PHONE 5555555555 ADDRESS -

PATIENT'S MOTHER'S MAIDEN NAME

Holske

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