Clinical note · #39
Consultation
Patient: Emily Rogers
Age: 45
Place of Service: Office – Outpatient
Patient Status: New Patient
Insurance: Commercial HMO
Referring Provider: Dr. K. Shah (Family Medicine)
Reason for Consultation: Dermatology consultation for evaluation of a pigmented skin lesion.
Chief Complaint: Concern about a mole on the left forearm.
History of Present Illness (HPI):
The patient is a 45-year-old female referred for dermatologic evaluation of a pigmented lesion on the left forearm that was noted during a routine primary care visit. The lesion has been present for several years with minimal change in size or color.
She denies bleeding, pain, pruritus, rapid growth, or color variation. There is no personal or family history of melanoma. The referring provider requested confirmation of benignity and management recommendations.
Review of Systems (ROS):
- Integumentary: Single pigmented lesion on left forearm
- Constitutional: Denies weight loss or fatigue
- All other systems reviewed and negative
Past, Family, and Social History:
- PMH: No significant medical history
- PSH: None
- FH: No family history of skin cancer
- SH: Denies tobacco use; occasional sunscreen use
Physical Examination:
- Skin: 4 mm symmetric, evenly pigmented nevus on left forearm
- No asymmetry, border irregularity, or color variation noted
- No additional suspicious lesions identified
Assessment:
- Benign melanocytic nevus
Plan:
- Provided reassurance regarding benign findings
- No biopsy or intervention indicated at this time
- Educated patient on ABCDE warning signs of melanoma
- Consultation report to be sent to referring provider