🔬 DermSpX

note (synthesized)

- **Patient Information:**
  - Name: James Kelly
  - DOB: 09/24/1935
  - MRN: 11547
- **Past Medical History:**
  - ID=16166
  - Reason=scan, wait
  - Location=face
  - Problem=spots
  - PriorTreatment=lesion on right cheek has been treated before with liquid nitrogen
  - Biopsy=several since 1972 when melanoma on chest was removed-all benign since then.
  - Feel=fine
  - BloodThinning=Yes
  - SunContact=golf, tennis, paddle
- **Family History:**
  - ID=16165
  - Smoker=not since 1968
- **Allergies:**
  - none known
- **Pathology History (62 events):**
  - **2021-07-06:** Left preauricular cheek — SKIN, LEFT PREAURICULAR CHEEK, SHAVE BIOPSY:SUPERFICIAL FRAGMENTS OF AT LEAST HYPERTROPHIC ACTINIC KERATOSIS
  - **2021-07-06:** ? — TBU
  - **2023-07-27:** Left cheek — BASAL CELL CARCINOMASKIN, LEFT CHEEK, SHAVE AND ELECTRODESICCATION AND CURETTAGE:BASAL CELL CARCINOMA, NODULAR TYPE, EXT
  - **2023-07-27:** ? — SCHEDULED IN PERSON FU
  - **2025-04-24:** right upper back — SQUAMOUS CELL CARCINOMAFINAL DIAGNOSIS A-SKIN, RIGHT UPPER BACK, SHAVE AND ELECTRODESSICATION AND CURETTAGE:SUPERFICIAL 
  - **2025-04-24:** ? — TBU
  - **2025-12-09:** Left preauricular area — SQUAMOUS CELL CARCINOMAFINAL DIAGNOSISA-SKIN, LEFT PREAURICULAR AREA, SHAVE AND ED AND C:INVASIVE SQUAMOUS CELL CARCINOM
  - **2025-12-09:** ? — TBU
  - **2026-02-27:** right arm — SQUAMOUS CELL CARCINOMAFINAL DIAGNOSIS A-SKIN, RIGHT ARM, ED AND C:INVASIVE SQUAMOUS CELL CARCINOMA, WELL-DIFFERENTIATED
  - **2026-02-27:** ? — TBU
  - *(+52 earlier events; see full list)*
- *Source: 62 extracted path events; 28 pathology PDFs on file. CSC pipeline data: see surveillance section above.*

rx (synthesized)

- **Active Medications:**
  - none
- **Recent Prescriptions:**
  - **2026-03-17:** Triamcinolone Cream As directed Topical cream Twice daily Topical Twice daily
  - **2025-12-23:** efudex Cream apply BID for a week
  - **2025-12-23:** tacrolimus 0.1% ointment apply nightly
  - **2022-02-24:** Triamcinalone 0.1% Cream BID
  - **2017-10-31:** Lac-Hydrin 12% Cream BID
  - **2015-03-17:** Ketoconazole 2% Cream BID
  - **2013-07-25:** Clobetasol 0.05% cream BID
  - **2011-02-08:** Tacrolimus 0.03% cream apply BID
  - **2007-12-11:** Imiquimod 5% cream (Aldara®)
  - **2006-01-13:** Hydrogen Peroxide or Bactine, 2-3 times daily for one month
  - **2005-08-12:** Terbinafine 250 mg p.o. Q.D. x one week then repeat in three months
  - **2004-10-14:** Ketaconazole 2% cream BID
  - **2001-03-23:** Exelderm solution BID to the affected nails
  - **2001-02-09:** Tetracycline 250 mg po BID
  - **2000-06-16:** Efudex Cream apply BID

code (synthesized)

- **Recent ICD/CPT Codes:**
  - **2026-03-17:**
    - ICD: C44.321
    - CPT: 99212 Return Visit
  - **2026-02-27:**
    - ICD: C44.321
    - CPT: 17263  Mlg Dest 2-3 cm
  - **2026-02-26:**
    - ICD: C44.622 Squamous Cell Carcinoma Right upper limb including shoulder
    - CPT: 99212 Return Visit
  - **2026-01-13:**
    - ICD: L57.0  Actinic Keratosis
    - CPT: 99212 Return Visit, J7345 AMELUZ   70621-101-01, 96574 Debridement with Red Light treatment
  - **2025-12-23:**
    - ICD: C44.329 Squamous Cell Carcinoma of skin of other parts of face
    - CPT: 99213 Return Visit
  - **2025-12-10:**
    - ICD: C44.329 Squamous Cell Carcinoma of skin of other parts of face
    - CPT: 17282  Mlg Dest 1.1-2 cm
  - **2025-05-09:**
    - ICD: D04.5 Carcinoma in situ of skin of trunk, L57.0  Actinic Keratosis, L57.0  Actinic Keratosis
    - CPT: 99212 Return Visit, 17000 Destruction, skin, 1st, 17003 Destruction, skin, 2-14
  - **2025-04-25:**
    - ICD: D04.5 Carcinoma in situ of skin of trunk
  - **2025-04-24:**
    - ICD: D04.5 Carcinoma in situ of skin of trunk, L57.0  Actinic Keratosis, L57.0  Actinic Keratosis
    - CPT: 17263  Mlg Dest 2-3 cm, 17000 Destruction, skin, 1st, 17003 Destruction, skin, 2-14
  - **2025-04-23:**
    - ICD: D22.9, Z85.820 Pers.Hist.MM, L57.0  Actinic Keratosis
    - CPT: 99214 Return Visit, 96904 Whole Body Photography
  - **2024-11-18:**
    - ICD: L57.0  Actinic Keratosis, L57.0  Actinic Keratosis
    - CPT: 17000 Destruction, skin, 1st, 17003 Destruction, skin, 2-14
  - **2024-10-21:**
    - ICD: L57.0  Actinic Keratosis, L57.0  Actinic Keratosis
    - CPT: 17000 Destruction, skin, 1st, 17003 Destruction, skin, 2-14
- **Path-confirmed Diagnoses:**
  - Basal cell carcinoma: 7 confirmed event(s)
  - Squamous cell carcinoma: 11 confirmed event(s)

note (existing — what Dermatoscan reads now)

**Patient Information:**
- Age: 87 years old (as of 2023)
- Gender: Male
- Occupation: Retired, previously in Broadcast Investment Banking
- Height: 5'10"
- Weight: 160 lbs
- Hair: Red
- Eyes: Green
- Marital Status: Married
- Born: September 24, 1935

**Medical History:**
- History of melanoma on the chest, removed in 1972.
- History of skin cancer, including actinic keratosis and basal cell carcinoma.
- History of seborrhea and acne rosacea.
- History of onycholysis with possible mixed infection or psoriasis.
- Periodic acid reflux and some musculoskeletal stiffness.
- No diabetes, no family history of skin cancer or diabetes.
- Former smoker, quit in 1968.
- Engages in activities with sun exposure such as golf, tennis, and paddle.

**Key Visits and Findings:**

1. **2000-06-16:**
   - Referred by Dr. Olin for bumps around the eyes.
   - >50 nevi with significant atypia; possible atypical nevus syndrome.
   - Seborrhea diagnosed; treatment with Aclovate and Nizoral creams.

2. **2000-07-27:**
   - >5000 pigmented lesions, none with significant atypia.
   - Severe sun damage noted.
   - Persistent seborrhea; treatment with Triamcinolone cream.

3. **2001-02-09:**
   - Complaints of central facial erythema; diagnosed with acne rosacea.
   - Onycholysis noted; toenail cultured for fungi.

4. **2001-03-23:**
   - Actinic keratosis on the face treated with liquid nitrogen.
   - Onycholysis with possible mixed infection or psoriasis; prescribed Exelderm solution.

5. **2005-05-02:**
   - Actinic keratosis on the face treated with cryodestruction.

6. **2020-01-22:**
   - Total body exam showed >50 nevi with significant atypia.
   - Basal cell carcinoma on the left shoulder treated with electrodessication and curettage.

7. **2023-06-26:**
   - Total body exam with melanoscan; >50 nevi with significant atypia.
   - Growing nevomelanocytic skin lesions noted, not suggestive of melanoma.
   - Lesion on right cheek treated with liquid nitrogen; possible actinic keratosis or squamous cell carcinoma.

**Doctor's Findings:**
- The patient has a history of melanoma and other skin cancers, with ongoing monitoring and treatment for various skin lesions.
- Regular follow-ups and skin examinations are conducted to monitor for new or changing lesions.
- Treatments have included cryodestruction, liquid nitrogen application, and topical creams for seborrhea and other skin conditions.
- The patient has been educated on self-examination and the warning signs of melanoma.

rx (existing)

The prescription record for the patient under the care of dermatologist Dr. Drugge spans from June 16, 2000, to February 24, 2022. Over this period, the patient received various topical and oral medications, primarily for dermatological conditions. 

1. **Initial Prescriptions (2000-2001):**
   - **Efudex Cream** was prescribed for scalp and cheek lesions, with a follow-up prescription for **Nizoral Cream** and **Aclovate Cream** for daily application. If these were ineffective, **Tacrolimus 0.03% Cream** was to be used twice daily.
   - **Triamcinalone 0.1% Cream** was prescribed in July 2000 for twice-daily application.
   - In February 2001, **Tacrolimus 0.03% Cream** was re-prescribed, alongside **Tetracycline 250 mg** for oral administration twice daily.
   - **Exelderm Solution** was prescribed in March 2001 for nail application.

2. **Mid-2000s Prescriptions (2004-2007):**
   - **Ketoconazole 2% Cream** was prescribed in October 2004 for facial application.
   - In August 2005, **Terbinafine 250 mg** was prescribed for oral use over a week, with a repeat after three months.
   - January 2006 saw a prescription for **Hydrogen Peroxide or Bactine** for topical use.
   - In December 2007, **Imiquimod 5% Cream** was prescribed for facial or scalp lesions, and **Tacrolimus 0.03% Cream** was re-prescribed.

3. **2010s Prescriptions:**
   - **Triamcinalone 0.1% Cream** was prescribed in July 1910 (likely a typographical error for 2010) and again in February 2011, with a large quantity dispensed for back application.
   - **Ketoconazole 2% Cream** was prescribed in October 2014 and March 2015 for chest and affected areas, respectively.
   - **Lac-Hydrin 12% Cream** was prescribed in January 2017 and October 2017 for general and facial application.

4. **Recent Prescription (2022):**
   - **Triamcinalone 0.1% Cream** was prescribed in February 2022 for use after dilute bleach baths.

Throughout the years, the patient has been prescribed a variety of creams and solutions, primarily for topical application, with some oral medications. The prescriptions often included refills, indicating ongoing treatment for chronic dermatological conditions.

code (existing)

The ICD/CPT code record for the patient under the care of dermatologist Dr. Drugge spans from June 16, 2000, to July 12, 2024. The records indicate a variety of dermatological conditions and procedures over the years, with a focus on skin lesions, keratoses, and carcinomas. 

1. **Common Diagnoses:**
   - **Actinic Keratosis (ICD: 702.0, L57.0):** This is the most frequently recorded diagnosis, appearing consistently throughout the years. It is a precancerous condition caused by sun damage.
   - **Nevus (ICD: 216.9, D22.9):** Benign skin lesions, often referred to as moles, are also commonly noted.
   - **Basal Cell Carcinoma (BCC) (ICD: 173.3, C44.319, C44.619, C44.01, C44.219):** This is a type of skin cancer that appears multiple times in the records, indicating ongoing monitoring and treatment.
   - **Seborrheic Dermatitis (ICD: 690.10):** A chronic inflammatory skin condition is noted occasionally.
   - **Personal History of Malignant Melanoma (ICD: V10.82, Z85.820):** This indicates a history of melanoma, necessitating regular follow-ups and monitoring.

2. **Common Procedures:**
   - **Destruction of Skin Lesions (CPT: 17000, 17003, 17004):** This procedure is frequently performed, particularly for actinic keratosis, indicating a proactive approach to managing precancerous lesions.
   - **Whole Body Photography (CPT: 96904):** Used for monitoring changes in skin lesions, especially in patients with a history of melanoma.
   - **Biopsies (CPT: 11100, 11102):** Conducted to diagnose skin lesions and confirm the nature of suspicious growths.
   - **Mohs Surgery (CPT: 17311):** A precise surgical technique used to treat skin cancer, particularly BCC, is noted in the records.
   - **Malignant Destruction (CPT: 17261, 17271, 17272, 17282):** Procedures for the removal of malignant skin lesions are recorded, reflecting treatment for skin cancers.

3. **Trends and Observations:**
   - The records show a consistent pattern of follow-up visits (CPT: 99213, 99214) and return visits (CPT: 99212), indicating regular monitoring and management of the patient's dermatological health.
   - There is a notable emphasis on the treatment and monitoring of actinic keratosis and basal cell carcinoma, reflecting the patient's ongoing risk for skin cancer.
   - The use of advanced procedures like Mohs surgery and whole-body photography suggests a comprehensive approach to skin cancer management.

Overall, the records reflect a thorough and consistent approach to dermatological care, with a focus on early detection and treatment of skin lesions to prevent progression to more serious conditions. The patient's history of melanoma and basal cell carcinoma necessitates regular monitoring and intervention, as evidenced by the frequent procedures and follow-up visits documented.

Provenance