AI Scribe for Dermatologists

CHIEF COMPLAINT:
Annual full-body skin exam. Patient also notes a "new spot" on the left upper back that her husband flagged.

HPI:
54-year-old fair-skinned (Fitzpatrick II) female with prior history of two basal cell carcinomas (left nasal sidewall, 2021 and right preauricular cheek, 2023, both Mohs-cleared) and a personal history of severe blistering sunburns in adolescence. Patient denies family history of melanoma. The lesion of concern on the left upper back has been present for "months" but the patient feels it has darkened and developed an irregular edge over the past 6-8 weeks. No pruritus, no bleeding. Last full-body skin exam: 14 months ago.

Sun exposure: Lifeguard 1989-1994. Currently uses SPF 50 daily on face only.
Medications: Hydrochlorothiazide 25 mg daily (note: photosensitising), atorvastatin 20 mg daily.
Allergies: NKDA.

OBJECTIVE:
Vitals: BP 128/76, HR 72, BMI 24.1
Skin type: Fitzpatrick II
Total skin examination performed with patient gowned, including scalp, ears, retroauricular folds, oral mucosa, palms, soles, interdigital web spaces, and gluteal cleft.

Findings by site:
- Scalp/face/neck: Multiple actinic keratoses on the bald scalp vertex and forehead, ranging 2-4 mm, scaly and erythematous. No suspicious pigmented lesions.
- Trunk (anterior): Several benign-appearing cherry angiomas. Stable seborrheic keratoses on the right flank.
- Trunk (posterior): LESION OF CONCERN — left upper back, 8 cm lateral to the spine at T3 level. 7 mm irregular pigmented macule. ABCDE: Asymmetric, irregular and notched border, three colours (light brown, dark brown, pink-grey area suggestive of regression), 7 mm diameter, evolving per patient. Dermoscopy: atypical pigment network at the inferior border, blue-white veil-like structure centrally, peripheral globules. Suspicious for melanoma in situ versus invasive melanoma.
- Upper extremities: Solar lentigines on dorsal hands. No atypical nevi.
- Lower extremities: A few benign compound nevi, all symmetric, uniform colour, <5 mm. Stable from prior photographs.

PROCEDURE PERFORMED:
After informed verbal and written consent including risks of bleeding, infection, scar, pigmentary change, and possible need for further excision, the left upper-back lesion was photographed, marked with 1 mm margins, and locally anaesthetised with 1% lidocaine with epinephrine, 0.5 mL. A 6 mm punch biopsy was performed sampling the most atypical area. Hemostasis achieved with aluminium chloride and a single 4-0 nylon simple interrupted suture. Sterile dressing applied.
Specimen submitted to dermpath for evaluation; "rule out melanoma" noted on requisition.

ASSESSMENT:
1. Atypical pigmented lesion, left upper back — clinically and dermoscopically concerning for melanoma; awaiting pathology. (D48.5 / D03.5 pending)
2. Multiple actinic keratoses, scalp and forehead. (L57.0)
3. History of basal cell carcinoma x2, status post Mohs. (Z85.828)

PLAN:
1. Punch biopsy results to be reviewed within 5-7 business days; office will call. If melanoma in situ or invasive melanoma is confirmed, wide local excision will be planned per NCCN guidelines based on Breslow depth.
2. Field treatment for actinic keratoses on scalp/forehead: 5-fluorouracil 5% cream applied BID for 3 weeks. Discussed expected brisk inflammatory reaction; patient verbalised understanding. Alternative options of cryotherapy and PDT also discussed.
3. Reinforced strict daily broad-spectrum SPF 50+ to all sun-exposed areas, not just face. Wide-brimmed hat, UPF 50 long-sleeve sun shirt for outdoor activity. Self-skin-exams monthly with partner assistance for back.
4. Continue hydrochlorothiazide per PCP — patient counseled regarding photosensitising effect.
5. Return to clinic in 6 months for routine surveillance, sooner if biopsy confirms melanoma.

CPT: 99214-25 (E&M, moderate complexity), 11104 (punch biopsy, single lesion).
Time: Total visit time 28 minutes, more than half spent in counseling and care coordination.