13 Jun Basal Cell Carcinoma of the skin of other part of trunk
Question
Jim is a roofer who may have these differential diagnoses
A Basal Cell Carcinoma of the skin of other part of trunk
B. Squamous Cell Carcinoma of the skin of other part of trunk
C Malignant Melanoma of other part of the trunk
Assesment
Skin: Skin warm, dry, and intact. Physical exam: Freckles and numerous nevi noted to face, chest, back, and arms. Asymmetrical lesion with irregular border noted on right shoulder with a diameter of 8 mm. The lesion is black and purple and slightly raised.
HEENT: Head normocephalic. Hair thick and distribution even throughout scalp.
Eyes: Sclera clear. Conjunctiva: white.
Neck supple. Mild cervical lymphadenopathy or tenderness noted. Thyroid midline, small, and firm without palpable masses.
Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored
CV: Heart S1 and S2 noted, RRR, no murmurs, noted. Peripheral pulses equally bilaterally
Based on your differential diagnosis list and the physical exam data, are there any additional tests you would like? Any additional Diagnoses or annual screenings that need to be addressed?
What are your diagnoses with ICD-10 code for Jimmy?
Plan for each primary diagnosis based on current evidence-based journal article.
Further diagnostic work-up not included above.
Medications
Referrals
Conservative measures
Patient education
Follow-up plan
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