🔬 DermSpX

note (synthesized)

- **Patient Information:**
  - Name: Joseph Coppola Jr.
  - DOB: 06 21 1944
  - MRN: 8805
- **Past Medical History:**
  - ID=3545
  - Reason=check on chest and shoulder
  - Notice=several months
  - Problem=none, its just there
  - Feel=.
  - Past=Diabetic15 years Seborrea 31 years
  - BloodThinning=Yes
  - SunContact=Condo in Fla. couple of hours a day
- **Family History:**
  - ID=3545
  - Diabetes=Yes
  - Smoker=quit 27 years ago
- **Pathology History (7 events):**
  - **2002-10-08:** Left shoulder — WELL-DIFFERENTIATED SQUAMOUS CELL CARCINOMA
  - **2002-10-08:** ? — TBU
  - **2008-07-18:** Left knee — VERRUCA VULGARIS AND CORNIFIED CELLS OF AN ATYPICAL KERATINOCYTIC LESION
  - **2008-07-18:** chest — SQUAMOUS-CELL CARCINOMA, SOLAR KERATOTIC TYPE, SUPERFICIAL (SOLAR KERATOSIS)
  - **2008-07-18:** ? — TBU
  - **2024-09-03:** right anterior shoulder — SQUAMOUS VS BASAL CELL CARCINOMA VS IRRITATED SK A-SKIN, RIGHT ANTERIOR SHOULDER, SHAVE AND CURETTAGE:BASAL CELL CARCINO
  - **2024-09-03:** ? — TBU
- *Source: 7 extracted path events; 2 pathology PDFs on file. CSC pipeline data: see surveillance section above.*

rx (synthesized)

- **Active Medications:**
  - Lantus — every 24 hours
- **Recent Prescriptions:**
  - **2024-08-22:** Zosyn shampoo. 2.5%. Shampoo. Topical.
  - **2022-07-20:** Fluocinonide 0.05% solution BID
  - **2021-09-27:** Selenium sulfide 2.5% lotion QD
  - **2018-08-28:** Selsun Lotion 2.5% apply daily as needed
  - **2018-08-28:** CVS Newfield
  - **2017-05-23:** selsun shampoo 2.25% apply daily as needed
  - **2016-09-09:** Nizoral 2% Cream BID
  - **2016-05-04:** Fluocinonide 0.05% Topical Solution BID
  - **2014-08-27:** Selsun Shampoo
  - **2013-01-29:** Triamcinalone 0.1% Cream daily
  - **2007-07-10:** Void
  - **2007-07-10:** Ultravate ointment BID PRN Itching
  - **2007-07-10:** Nizoral cream BID

code (synthesized)

- **Recent ICD/CPT Codes:**
  - **2024-08-22:**
    - ICD: C44.321 - Squamous cell carcinoma of skin of chest.
    - CPT: 17260 - Destruction, malignant lesion, trunk, arms, or legs; lesion diameter 0.5 cm or less.
  - **2023-09-07:**
    - ICD: L57.0  Actinic Keratosis
    - CPT: 99213 Return Visit
  - **2022-07-20:**
    - ICD: Z41.1  Cosmetic procedure, Z41.1  Cosmetic procedure
    - CPT: 17110  Destruction, skin, up to 14
  - **2021-09-27:**
    - ICD: L82.1  Seborheic  Keratosis, non-inflamed
    - CPT: 99212 Return Visit
  - **2020-08-26:**
    - ICD: D69.2 Purpura
    - CPT: 99213 Return Visit
  - **2020-07-20:**
    - ICD: L85.9 Epidermal thickening, unspecified (skin tag)
    - CPT: 11200  Skin tags, first 15
  - **2019-06-04:**
    - ICD: D22.9 Melanocytic nevi, L82.1  Seborheic  Keratosis, non-inflamed
    - CPT: 99213 Return Visit
  - **2018-08-16:**
    - ICD: L57.0  Actinic Keratosis, D22.9 Melanocytic nevi
    - CPT: 17000 Destruction, skin, 99213 Return Visit
  - **2017-10-17:**
    - ICD: D22.9 Melanocytic nevi
    - CPT: 99213 Return Visit
- **Path-confirmed Diagnoses:**
  - Basal cell carcinoma: 1 confirmed event(s)
  - Squamous cell carcinoma: 1 confirmed event(s)

note (existing — what Dermatoscan reads now)

### Patient Information:
- **Name:** Not provided
- **Date of Birth:** June 21, 1944
- **Age:** 79 years old (as of the latest visit in 2023)
- **Gender:** Male
- **Marital Status:** Married
- **Occupation:** Printer
- **Height:** 5' 8"
- **Weight:** 190 lbs
- **Hair Color:** Brown
- **Eye Color:** Brown
- **Allergies:** NKDA (No Known Drug Allergies)
- **Tobacco Use:** Quit 27 years ago
- **Sun Exposure:** Condo in Florida, spends a couple of hours a day in the sun

### Medical History:
- **Diabetes:** 15 years
- **Seborrhea:** 31 years
- **Medications:**
  - Lantus (daily)
  - Avapro
  - Lisinopril
  - Glucophage
  - Lipitor
  - Humalog
- **Anticoagulants:** NSAIDs, Vitamin E
- **Family History:**
  - Father had diabetes
  - No family history of melanoma or skin cancer
- **Skin Cancer Risk Assessment:** Moderate (scores ranging from 10 to 12 over the years)
- **History of Skin Cancer:** Self, but no melanoma

### Key Visits and Findings:

#### 2002-10-08:
- **Complaint:** Growth on left shoulder
- **Findings:** 4 mm erythematous keratotic nodule
- **Impression:** Cutaneous horn (differential diagnosis: AK, SCC, filiform wart)
- **Plan:** Lesion excised for biopsy

#### 2007-07-10:
- **Complaint:** Check-up and growth on left knee
- **Findings:** >50 nevi, 10 with significant atypia; multiple pigmented lesions
- **Impression:** Growing Nevomelanocytic Skin Lesion, Dysplastic nevus syndrome
- **Plan:** Follow-up in one year

#### 2008-07-18:
- **Complaint:** Check-up, spot on chest, bumps on left knee
- **Findings:** 1.5 cm keratotic nodule on chest, 25 keratotic papules on left knee
- **Impression:** Squamous Cell Carcinoma (chest), Verruca vulgaris and psoriasis (knee)
- **Plan:** Electrodessication and curettage, shave biopsy

#### 2010-02-02:
- **Complaint:** Annual check-up, spot on chest
- **Findings:** 12 erythematous nodules on chest
- **Impression:** Acne keloidalis
- **Plan:** Intralesional TMC injections

#### 2014-08-27:
- **Complaint:** Spots to check
- **Findings:** Darkening asymmetrical brown papules
- **Impression:** Growing Pigmented Skin Lesions, seborrheic keratosis type
- **Plan:** Watch for melanoma warning signs

#### 2016-09-09:
- **Complaint:** Follow-up
- **Findings:** Fine greasy scale on glabella and paranasal areas
- **Impression:** Seborrhea
- **Plan:** Nizoral Cream BID

#### 2017-10-17:
- **Complaint:** General skin exam
- **Findings:** Very few asymmetrical brown papules
- **Impression:** Pigmented Skin Lesions, melanocytic and seborrheic keratosis type

#### 2018-08-16:
- **Complaint:** Visual skin exam
- **Findings:** 2 hyperkeratotic erythematous macules on the right side of the head
- **Impression:** Actinic Keratosis
- **Plan:** LN2 treatment

#### 2020-07-20:
- **Complaint:** Check spot on face
- **Findings:** 3 mm necrotic papule on right nipple
- **Impression:** Skin Tags, Irritated
- **Plan:** LN2 treatment

#### 2021-09-27:
- **Complaint:** Check-up on spot on left biceps
- **Findings:** 4 mm hyperpigmented verrucous macule
- **Impression:** Seborrheic Keratosis
- **Plan:** Reassurance

#### 2022-07-20:
- **Complaint:** Spots of concern
- **Findings:** 6 sessile keratotic papules on face, 17 on body
- **Impression:** Seborrheic keratoses
- **Plan:** Cryodestruction

#### 2023-09-07:
- **Complaint:** Spots of concern
- **Findings:** Erythematous well-demarcated scaling macules on face
- **Impression:** Actinic Keratosis
- **Plan:** Lesions deemed too superficial for treatment at this time

### Summary:
The patient is a 79-year-old male with a history of diabetes and seborrhea. He has had multiple skin conditions over the years, including seborrheic keratosis, actinic keratosis, squamous cell carcinoma, and various pigmented skin lesions. He has undergone several treatments, including cryodestruction, electrodessication, and curettage. His skin cancer risk is moderate, and he has no personal or family history of melanoma. Regular follow-ups and skin exams are part of his ongoing care plan.

rx (existing)

The prescription record for the patient under the care of dermatologist Dr. Drugge spans from 2007 to 2024. The summary of the prescriptions is as follows:

### 2007-07-10
1. **Ultravate Ointment**: Apply BID (twice daily) as needed for itching. Dispense 30 grams with two refills.
2. **Nizoral Cream**: Apply BID. Dispense 30 grams with six refills.

### 2013-01-29
1. **Triamcinalone 0.1% Cream**: Apply daily to the entire body after showers while wet before toweling dry. Dispense 454 grams with two refills.

### 2014-08-27
1. **Fluocinonide 0.05% Topical Solution**: Apply BID to affected areas. Dispense 60 ml with six refills.
2. **Selsun Shampoo**: Over-the-counter, no specific instructions provided.

### 2015-06-18
1. **Selsun Shampoo 2.25%**: Apply daily as needed. Dispense 240 ml with six refills.

### 2016-02-22
1. **Fluocinonide 0.05% Topical Solution**: Apply BID to affected areas. Dispense 60 ml with six refills.

### 2016-05-04
1. **Fluocinonide 0.05% Topical Solution**: Apply BID. Dispense 60 ml with six refills.

### 2016-09-09
1. **Nizoral 2% Cream**: Apply BID. Dispense 30 grams with one refill.

### 2016-11-07
1. **Selsun Shampoo 2.25%**: Apply daily as needed. Dispense 240 ml with six refills.

### 2017-05-23
1. **Selsun Shampoo 2.25%**: Apply daily as needed. Dispense 240 ml with twelve refills.

### 2018-08-28
1. **Selsun Lotion 2.5%**: Apply daily as needed. Dispense 120 ml with twelve refills.
2. **CVS Newfield**: No specific instructions or details provided.

### 2021-09-27
1. **Selenium Sulfide 2.5% Lotion**: Apply daily to the scalp. Dispense 4 fl. oz with ten refills.

### 2022-07-20
1. **Fluocinonide 0.05% Solution**: Apply BID to affected areas. Dispense 60 ml with twelve refills.

### 2024-08-22
1. **Zosyn Shampoo 2.5%**: Apply daily as needed. Dispense 4 ounces with six refills.

Throughout the years, the patient has been prescribed various topical treatments primarily for conditions requiring anti-inflammatory, antifungal, and anti-itch medications. The most frequently prescribed medications include Fluocinonide, Selsun Shampoo, and Nizoral Cream, with varying instructions and refill quantities.

code (existing)

The ICD/CPT code record for the patient under the care of dermatologist Dr. Drugge spans from 1998 to 2024, detailing various dermatological conditions and procedures. Below is a comprehensive summary of the findings:

### 1998
- **July 17**: Diagnosed with Seborrheic Keratosis (ICD: 702.11). Procedure: Return Visit (CPT: 99212).
- **August 14**: Diagnosed with Actinic Keratosis (ICD: 702.0) and abnormal pigmentation (ICD: 709.00). Procedures: Destruction of skin lesions (CPT: 17000, 17003).

### 2002
- **October 8**: Diagnosed with Actinic Keratosis (ICD: 702.0). Procedure: Biopsy (CPT: 11100).
- **October 22**: Diagnosed with Neoplasm of the upper limb (ICD: 173.6). Procedure: Return Visit (CPT: 99212).

### 2003
- **November 10**: Diagnosed with Neoplasm (ICD: 216.9). Procedure: Return Visit (CPT: 99213).

### 2005
- **May 23**: Diagnosed with Neoplasm (ICD: 216.9). Procedure: Return Visit (CPT: 99213).

### 2007
- **July 10**: Diagnosed with Dysplastic Nevus Syndrome (ICD: 216.9), Nevus (ICD: 216.9), and Psoriasis (ICD: 696.1). Procedures: Whole Body Integumentary Photography (CPT: 96904), Return Visit (CPT: 99213), and Injections (CPT: 11900).

### 2008
- **July 18**: Diagnosed with Squamous Cell Carcinoma of the trunk (ICD: 173.5), Verruca Vulgaris (ICD: 078.19), and Psoriasis (ICD: 696.1). Procedures: Malignant lesion destruction (CPT: 17262), skin lesion destruction (CPT: 17110), and Biopsy (CPT: 11100).

### 2010
- **February 2**: Diagnosed with Keloid (ICD: 701.4). Procedures: Injections (CPT: 11901) and Kenalog (CPT: J3301).

### 2011
- **May 17**: Diagnosed with Nevus (ICD: 216.9). Procedures: Return Visit (CPT: 99213) and Whole Body Integumentary Photography (CPT: 96904).

### 2013
- **January 29**: Diagnosed with Nevus (ICD: 216.9) and Atopic Dermatitis (ICD: 691.8). Procedure: Return Visit (CPT: 99213).

### 2014
- **March 11**: Diagnosed with Seborrheic Keratosis (ICD: 702.11). Procedure: Return Visit (CPT: 99213).
- **August 27**: Diagnosed with Seborrheic Keratosis (ICD: 702.11). Procedure: Return Visit (CPT: 99213).

### 2015
- **June 18**: Diagnosed with Nevus (ICD: 216.9) and Seborrheic Dermatitis (ICD: 690.10). Procedure: Return Visit (CPT: 99213).

### 2016
- **February 22**: No diagnoses or procedures recorded.
- **May 4**: Diagnosed with Seborrheic Dermatitis (ICD: L21.9) and Actinic Keratosis (ICD: L57.0). Procedures: Return Visit (CPT: 99212) and skin lesion destruction (CPT: 17000).
- **September 9**: Diagnosed with Seborrheic Dermatitis (ICD: L21.9) and non-inflamed Seborrheic Keratosis (ICD: L82.1). Procedure: Return Visit (CPT: 99213).
- **November 7**: No diagnoses or procedures recorded.

### 2017
- **May 23**: No diagnoses or procedures recorded.
- **October 17**: Diagnosed with Melanocytic Nevi (ICD: D22.9). Procedure: Return Visit (CPT: 99213).

### 2018
- **August 16**: Diagnosed with Actinic Keratosis (ICD: L57.0) and Melanocytic Nevi (ICD: D22.9). Procedures: Skin lesion destruction (CPT: 17000) and Return V

Provenance