What further questions do you have for Jimmy at this visit?

How come you didn’t follow up after your last appointment a year ago? (Non-compliance)

What happened to the blood pressure pills you were prescribed? Did another medical provider stop them? How has your blood pressure been running? (Uncontrolled hypertension)

• Do you wear sunscreen? (malignant melanoma, seborrheic keratosis, Non-melanoma skin cancer)
• Do you wear your shirt at work? (malignant melanoma, seborrheic keratosis, Non-melanoma skin cancer)
• How often are you in the sun? (malignant melanoma, seborrheic keratosis, Non-melanoma skin cancer)
• Do any of your moles/areas that hurt, bleed, scab, itch, non-healing? (non-melanoma skin cancer)
• Are any moles new? (malignant melanoma, seborrheic keratosis, Non-melanoma skin cancer)
• How long have you had this mole your wife is concerned about? (malignant melanoma, seborrheic keratosis, Non-melanoma skin cancer)
• What has changed about it? ((malignant melanoma, seborrheic keratosis, Non-melanoma skin cancer)
• Any history of skin cancer or any other cancer in your family? (Malignant melanoma)
• How many times have you been sunburnt? (malignant melanoma, seborrheic keratosis, Non-melanoma skin cancer)
• Have you considered quitting smoking? (Increased health risks for smokers)

Discussion Part Two (graded)

Further information: Jimmy states he does not use sunscreen, states he sweats it off, and it makes his hands slick. He states that he often takes off his shirt when on the roof, used to get sunburned all the time—“Now my skin is like leather.” Denies any red, scaly, or crusted areas that do not heal.

PE:  Height: 5 feet 10 inches, weight 200 pounds

SOAP Note

J.M., 58yo, M.

S.

CC- mole

HPI- Wife sent the patient in to have a mole looked at on his back. Patient has multiple moles and freckles he states, he's had all his life. Wife says the mole on his back looks different than the others and is growing. Jimmy states he does not use sunscreen, states he sweats it off, and it makes his hands slick.