Basal Cell Carcinoma of the skin of other part of trunk

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