Dermatology Consult Intake

Patient Name: Samuel Carter

DOB: [date]

Date of Consult: 2025-03-13

Referred by: [name]

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### Reason for Referral:

The patient is referred for evaluation of a pruritic nevus on the right knee that has been present for an unspecified duration. They have not responded to previous treatments.

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### History of Present Illness (HPI):

37-year-old male presents with a history of an itchy mole. The patient describes the lesion as located primarily on the lateral side of the right leg, just above the knee, with associated symptoms including itchiness. The patient has not attempted any previous treatments. There has been no associated fever, fatigue, or systemic symptoms.

Aggravating factors: None identified

Relieving factors: None identified

Changes noted: The patient is unsure if there have been changes in size, color, or other characteristics.

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### Past Medical History (PMHx):

No relevant dermatological history

History of anemia and hypoglycemia

### Past Surgical History:

History of a broken elbow at age four

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### Medications:

No chronic medication use

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### Allergies:

No known drug or environmental allergies

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### Family History:

No family history of skin cancer; family history of other cancers and diabetes in grandmother

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### Social History:

- Sun exposure: Not specified
- Tobacco use: Not specified
- Alcohol use: Not specified
- Occupation: Not specified

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### Physical Exam:

General:

- Skin Type: Fitzpatrick Type I
- Overall Skin Appearance: Not specified

Focused Dermatological Exam Findings:

1. Lesions:
    - Location: Lateral side of the right leg, just above the knee
    - Size/Shape: Not specified
    - Color: Not specified
    - Texture/Surface: Not specified
    - Distribution/Number: Single lesion
    - Evolution: Patient is unsure of changes
2. Hair: Not specified
3. Nails: Not specified
4. Mucosal Surfaces: Not specified

Investigations:

- Nevus mapping planned

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### Assessment:

The patient presents with a pruritic nevus on the right knee. Differential diagnosis includes potential skin cancer.

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### Plan:

Treatment Recommendations:

- Consider referral to dermatology for further evaluation and possible biopsy if indicated.

Patient Education:

- Educated the patient on monitoring the nevus for any changes in size, shape, color, or symptoms such as bleeding or increased pruritus.

Follow-Up:

- Follow up with primary care physician to discuss blood test results and potential causes of anemia and hypoglycemia.

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Electronically Signed on 2025-03-13

Avery Sinclair, MD

Dermatologist

Copied to: [Primary Care Physician, Referring Provider]