Problem:
Marty L Zeller I am seeing this patient at the request of Dr. Practon, his primary physician. Patient is a 59 y/o utility worker. He has been complaining of a bump on his back of this neck midline for the past three months. The bump has gradually grown in size and has begun to bleed. The bump is not painful but gets caught on his necklace and makes haircuts difficult. The patient has a family history of basal cell carcinoma. The patient has had moles removed prophylactically in the past. O: B/P: 120/80, Weight: 225, Temp: 98.6 Patient is a pleasant male. He has not noticed any other suspicious lesions elsewhere on his body. Nodule is approximately 0.7 cm ulcerated with uneven borders. A central crust is present. Skin on the back, arms, face, and hands appears sun damaged from years of working outdoors. A: Basal cell carcinoma. P: Electrodessication and curetting under local anesthesia. 1% Xylocaine injected in a pinwheel fashion. Polysporin cream applied. He is to take Advil for pain and reapply cream after showering. Return in 10 days for follow-up. A report will be sent to Dr. Practon with the findings of the visit.