Documenting a dermatology list
Skin check and procedure notes, excision records, and the histology letter to the GP when the pathology is reported.
Excision note and histology letter
The excision is dictated in the procedure room. The letter is drafted when the pathology report is uploaded.
Skin check. Left upper back, 9 by 7 millimetre pigmented lesion, her husband says it has changed over six months. Dermoscopy, atypical network with regression at one edge.
Excisional biopsy with 2 mm margins, ellipse along the skin tension lines, oriented with a suture at twelve o'clock. Lignocaine 1% with adrenaline, 4 mL.
3-0 Monocryl deep, 4-0 nylon interrupted to skin.
Two solar keratoses on the left forearm, liquid nitrogen.
Sutures out at day fourteen with the practice nurse. Review when the histology is back.
Lesion
L upper back, 9 × 7 mm pigmented lesion, reported change over 6 months. Dermoscopy: atypical network, regression structures at one edge.
Procedure
Excisional biopsy, 2 mm margins. Ellipse along RSTL, orientation suture at 12 o'clock. Lidocaine 1% with adrenaline 4 mL. Closure 3-0 Monocryl deep, 4-0 nylon interrupted.
Other
Solar keratoses ×2, L forearm: cryotherapy.
Plan
- Sutures out day 14 (practice nurse)
- Review on histology
When the pathology comes back
Dr Kathryn BrennanNorthside Family Practice
RE: Fraser, Joan (DOB 21/07/1961) · Synthetic patient
Dear Dr Brennan,
The lesion I excised from Mrs Fraser's left upper back on 14 September is a superficial spreading melanoma, Breslow thickness 0.4 mm, no ulceration, mitotic rate 0 per mm², clear of the deep and peripheral margins by 1.8 mm. This is pT1a.
I have booked a wide local excision with a 1 cm margin for 2 October. Sentinel node biopsy is not indicated at this thickness.
I will see her for skin checks every 6 months for 5 years, then yearly. I have shown her how to examine her own skin and asked her to come back sooner with any new or changing lesion.
Kind regards,Consultant dermatologist
