Sample Name: Verruca Vulgaris
Description: Bleeding lesion on cheek, irritated lesion on mandible. Verruca vulgaris versus SCC. Irritated nevus on mandible.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS:
The patient is a 50-year-old male who presents with chief complaint of a bleeding lesion on his left cheek, irritated lesion on his right mandible that he often touches when he is shaving and also pedunculated papules on his right neck that consistently catch on his clothes. He states that those lesions have been for a while and they bother him significantly. He has no past medical history of skin cancer. He has no family history of skin cancer. He does not have significant sun exposure and he does wear sunscreen.
PAST MEDICAL HISTORY:
No significant current medical problems.
PAST SURGERY HISTORY:
The patient is a videographer and teacher.
REVIEW OF SYSTEMS:
Signed and reviewed in the chart.
Upper body skin exam is performed of chest, abdomen, back, right arm, left arm, neck, eyelids, ears, and face were examined. On exam, the patient has a verrucous lesion on his right cheek. He also has an irritated and excoriated papule on his right mandible and two pedunculated papules on his right neck. Wound Care instructions provided to the patient.
IMPRESSION AND PLAN:
1. Verruca vulgaris versus SCC. Shave biopsy of the lesion was performed. Time-out was performed. Consent was signed. The lesion was anesthetized with 1 cc of lidocaine with epinephrine. Shave biopsy of the lesion was performed.
2. Irritated nevus on right mandible. Shave biopsy of the lesion was performed.
Keywords: dermatology, bleeding lesion, mandible, lesion, pedunculated, papules, verruca vulgaris, shave biopsy, nevus, acrochordons,