Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Visit:
New diagnosis of cutaneous squamous cell carcinoma (SCC)
Follow-up for known cutaneous SCC
II. History of Present Illness:
New diagnosis:
Discovery of a new suspicious skin lesion (describe location, size, color, shape, duration)
Any history of sunburns, excessive sun exposure, or tanning beds
Follow-up:
Date of prior SCC diagnosis and treatment
Any new or worsening symptoms (e.g., bleeding, pain, enlargement of the lesion)
Adherence to follow-up recommendations
III. Past Medical History:
Significant medical conditions (immunosuppression)
Previous surgeries (including any prior SCC excision)
History of actinic keratosis (precancerous skin lesions)
IV. Medications:
Current medications (including immunosuppressants)
V. Social History:
Sun exposure habits (history of sunburns, tanning)
Occupational sun exposure
VI. Physical Exam:
Vital signs (BP, HR, RR, Temp)
Skin exam:
Detailed examination of the entire skin surface for suspicious lesions.
Close examination of the primary SCC site (size, color, bleeding, ulceration, induration)
Lymph node examination (palpate for enlargement or tenderness)
VII. Diagnostic Studies (consider as appropriate):
Skin biopsy: Definitive diagnosis of SCC requires excisional biopsy with pathological examination.
Sentinel lymph node biopsy (SLNB): May be performed after primary SCC excision in high-risk cases to assess lymph node involvement.
Imaging studies (if indicated for suspected advanced disease): Chest X-ray, CT scan, PET scan – to evaluate for potential metastasis.
VIII. Assessment:
New diagnosis: Suspected or confirmed cutaneous SCC based on clinical presentation (suspicious lesion). Definitive diagnosis awaits biopsy results.
Follow-up: Evaluate status of known SCC and any signs of recurrence or metastasis.
IX. Plan:
New diagnosis:
Treatment options depend on the size, location, depth of invasion, and other factors.
Surgical excision with adequate margins is the most common treatment.
Other options include Mohs surgery (tissue-sparing technique), cryotherapy, or electrodessication and curettage (for superficial SCC).
Sentinel lymph node biopsy may be indicated in high-risk cases.
Further workup (imaging studies) may be needed to assess for potential metastasis in advanced stages.
Follow-up:
Management plan depends on the stage of SCC at initial diagnosis and presence of recurrence.
Regular skin cancer screenings are crucial for early detection of new or recurrent SCCs.
X. Prognosis:
Discuss the prognosis based on the stage and other factors of the SCC. Early-stage SCCs treated appropriately have a good prognosis.
The importance of sun protection and regular skin self-exams should be emphasized.
XI. Notes:
Include any additional observations or concerns, such as patient’s understanding of the diagnosis and treatment plan, potential side effects of treatment, need for emotional support, and referral to a dermatologist or surgical oncologist for definitive management.
XII. Resources:
Consider providing patient education materials on cutaneous squamous cell carcinoma from reputable sources (e.g., American Academy of Dermatology, Skin Cancer Foundation).