Dermatology Consultation

Patient Information

Patient Name: Arthur Pendelton

Date of Birth: 14/05/1958

Date of Consultation: 19/11/2023

Medical Record Number: MRN-8492014

Reason for Consultation

• Presenting Issue: Assessment of a non-healing skin lesion on the right cheek and an erythematous rash on the bilateral forearms.

Clinical History

• Symptoms: Slowly enlarging lesion on the right malar region that bleeds easily with minor trauma (e.g., towel drying). Pruritic, scaly erythematous plaques on bilateral dorsal forearms.
• Duration: Right cheek lesion present for 4 months; forearm rash present for 6 weeks.
• Previous Treatments: OTC hydrocortisone 0.5 % cream to forearms with minimal relief; pawpaw ointment to facial lesion.
• Relevant Past Medical History: Actinic keratosis (treated with cryotherapy 2021), HTN, hyperlipidaemia. Significant cumulative lifetime sun exposure (retired landscaper).
• Allergies: NKDA.

Examination Findings

• Skin Lesion/Rash Description: Right malar cheek: 8 mm pearly papule with rolled borders, central ulceration, and arborising telangiectasia noted on dermoscopy. Forearms: multiple poorly demarcated erythematous, xerotic plaques with fine scaling and mild excoriation.
• Distribution and Pattern: Solitary lesion on right sun-exposed cheek; symmetrical distribution of rash across extensor surfaces of bilateral forearms.
• Additional Observations: Fitzpatrick skin type II, extensive solar lentigines and actinic damage across face, neck, and upper limbs. No regional lymphadenopathy. No clinical signs of secondary bacterial infection.

Assessment

• Diagnosis/Working Diagnosis: Suspected nodular basal cell carcinoma (BCC) on the right cheek; asteatotic eczema with background actinic damage on bilateral forearms.
• Differential Diagnosis: Squamous cell carcinoma (SCC), amelanotic melanoma, or sebaceous hyperplasia for the facial lesion; allergic contact dermatitis or psoriasis for the forearm rash.

Investigations Ordered

• Biopsy: 3 mm punch biopsy of the right malar lesion edge performed under local anaesthetic (lidocaine 1 % with adrenaline) for histopathology to confirm BCC subtype.
• Blood Tests: FBC, U&E, LFTs, and 25-OH Vitamin D levels.

Treatment Plan

• Immediate Management: Punch biopsy site closed with a single 5-0 nylon interrupted suture. Prescribed mometasone furoate (Elocon®) 0.1 % ointment 1 application TOP daily for 2 weeks for the bilateral forearms, alongside regular liberal use of a soap-free emollient.
• Follow-Up Care: Review in 7 days for suture removal and discussion of histopathology results to plan definitive excision if malignancy confirmed.
• Patient Education: Discussed UV protection measures (broad-spectrum SPF 50+ sunscreen, wide-brimmed hat), regular self-skin checks, and soap avoidance.

Patient Instructions

• Medication Use: Apply mometasone furoate 0.1 % ointment thinly to the red, itchy areas on the forearms once daily at night for 14 days. Apply plain moisturising cream twice daily.
• Wound Care: Keep the biopsy dressing on the right cheek dry for 48 hours. Afterwards, wash gently with water and apply white soft paraffin (Vaseline®) daily until the stitch is removed.
• When to Seek Help: Return earlier if experiencing increasing pain, spreading redness, pus discharge, bleeding that does not stop with 10 minutes of firm pressure, or fever.

Patient Understanding

• Confirmed: Yes, the patient showed understanding of the diagnosis, proposed treatment, and follow-up arrangements.

Follow-Up

• Next Appointment: Appointment to review biopsy results and remove suture on 26/11/2023 at 10:30.
• Referral: Referral to plastic surgery or dermatology for definitive excision/Mohs surgery pending histopathology confirmation and margin assessment.

Signature

Dr Sarah Jenkins

General Practitioner, MBBS, FRACGP

Bayside Family Medical Practice, 142 Bay Street, Brighton VIC 3186 | Ph: (03) 9555 0192

Date: 19/11/2023