Full Skin Examination

Full Skin Examination

Current Concerns

• Changing pigmented lesion on upper back x 3 mos
• Rough, scaly spots on forehead and bald scalp
• Dry, erythematous rash on bilateral lower legs

Examination

• Face: 3 erythematous, gritty, hyperkeratotic papules on forehead consistent with actinic keratoses (AKs); mild facial telangiectasias.
• Ears: 4 mm erythematous scaly papule on R antihelix (AK); L ear NAD.
• Scalp: Androgenic alopecia; diffuse actinic damage with 2 gritty hyperkeratotic macules on vertex.
• Neck: Mild poikiloderma of Civatte laterally; 3 pedunculated acrochordons on R lateral neck.
• Chest: Scattered cherry angiomas; solar lentigines on upper chest.
• Abdomen: Well-healed 4 cm RLQ appendectomy scar; no suspicious pigmented lesions.
• Upper limbs: Diffuse solar lentigines on bilateral extensor forearms; skin otherwise intact.
• Hands: Mild dorsal actinic bronzing; nails without melanonychia, pitting, or onycholysis.
• Lower limbs: Bilateral 1+ pitting edema to mid-shin; erythematous, scaling plaques with hemosiderin staining on medial malleoli consistent with stasis dermatitis; prominent bilateral varicosities.
• Feet: Mild interdigital maceration 4th/5th webspace R foot; toenails thickened with distal subungual hyperkeratosis on bilateral halluces.
• Back: Multiple tan-to-brown stuck-on verrucous plaques (seborrheic keratoses); 1 asymmetric 7 mm x 5 mm macule on R suprascapular region with irregular borders and 2 shades of brown on dermoscopy (atypical nevus vs melanoma in situ).

Plan

• Cryotherapy (liquid nitrogen) performed today to 6 AKs (3 forehead, 2 vertex scalp, 1 R ear); wound care discussed.
• Punch biopsy (4 mm) of R suprascapular atypical pigmented lesion performed under local anesthesia (lidocaine 1% with epinephrine 1.5 mL SC); closed with 1x 4-0 nylon suture; specimen sent to pathology.
• Triamcinolone acetonide 0.1% ointment TOP BID to bilateral lower legs x 14 days for stasis dermatitis, then PRN.
• Compression stockings (20-30 mmHg) daily and leg elevation recommended for venous insufficiency.
• Terbinafine 1% cream TOP daily to R foot 4th/5th webspace x 2 wks for tinea pedis.
• Broad-spectrum SPF 50+ sunscreen daily and sun-protective clothing advised.
• Suture removal in 14 days; F/U in 2 wks to review biopsy pathology.

Billing

• D22.5 (Melanocytic nevi of trunk)
• L57.0 (Actinic keratosis)
• I87.2 (Venous insufficiency (chronic) (peripheral))
• B35.3 (Tinea pedis)
• L82.1 (Other seborrheic keratosis)