Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Subjective:
Briefly describe any changes the patient has noticed in the lentigo maligna lesion(s) since the last visit.
Inquire about any new symptoms like itching, bleeding, or pain.
Objective:
Skin exam:
Describe the location, size, color, and border characteristics (regular vs. irregular) of the lentigo maligna lesion(s).
Measure the lesion(s) in two perpendicular diameters (mm).
Note any changes compared to previous descriptions or photographs (if available).
Examine regional lymph nodes for enlargement.
Assessment:
Diagnosis: Confirm the diagnosis of lentigo maligna.
Disease activity: Based on the clinical exam, assess whether the lesion appears stable, enlarging, or showing signs of possible transformation (ABCD criteria – Asymmetry, Border irregularity, Color variation, Diameter > 6mm).
Plan:
Treatment:
Depending on the assessment and discussion with the patient, outline the recommended treatment plan. This may include:
Surgical excision with clear margins.
Destructive techniques (e.g., cryotherapy, curettage and electrodesiccation).
Topical chemotherapy (consider risks and benefits).
Mention the need for further workup (e.g., sentinel lymph node biopsy) if there is suspicion of spread.
Follow-up:
Schedule the next clinic visit for follow-up examination based on the treatment plan.
For lesions undergoing observation, recommend shorter follow-up intervals.
Instruct the patient to return sooner if they notice any changes in the lesion(s) or develop new symptoms.