Medical Record Analysis
This Dermatology Consultation Report contains 11 medical terms. Underline each term and write it in the list below the
report. Then explain each term as you would for a nonmedical person.
Dermatology Consultation Report
Reason for
Possible recurrence of basal cell carcinoma, left cheek
Consultation:
History of Present Patient is a 74-year-old male first seen by his regular physician five years ago for per-
Illness:
sistent facial lesions. Biopsies revealed basal cell carcinoma in two lesions, one on the
nasal tip and the other on the left cheek. These were successfully excised. The patient
noted that the left cheek lesion retumed approximately one year ago. Patient reports
pruritus and states the lesion is growing larger
Results of Physical Examination revealed a 10 x 14 mm lesion on left cheek 20 mm anterior to the ear. The
Exam:
lesion displays marked erythema and poorly defined borders. The area immediately
around the lesion shows depigmentation with vesicles.
Assessment:
Recurrence of basal cell carcinoma
Recommendations: Due to the lesion's size, shape, and recurrence, deep excision of the carcinoma through
the epidermis and dermis layers followed by dermatoplasty is recommended