HISTORY OF PRESENT ILLNESS
A 73-year-old man who is a veterinarian is seen here for the first time today. He has a history of squamous cell carcinoma on the left arm and a basal cell carcinoma on the right forehead near the temple, both in January 20XX. He says he has had a lesion on his forehead for approximately one year. He is concerned about what it is and thinks it may be another skin cancer. He is also concerned about another lesion that has been present for a while, just lateral to his right eye. He would also like a full skin check today. He uses a hat for sun protection. He has lived in California and has had significant sun exposure in the past.
REVIEW OF SYSTEMS: Otherwise well, no other skin complaints.
PAST MEDICAL HISTORY
Coronary artery disease status post bypass surgery, history of squamous and
basal cell carcinomas as noted above, hay fever, and hyperlipidemia. He
has had lipomas removed.
MEDICATIONS: Tylenol, tramadol, thyroxin, fish oil, flax seed oil, simvastatin, Zyrtec®, 5% saline in eyes.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: No family history of skin cancer or other skin problems.
SOCIAL HISTORY: Patient is a veterinarian. He recently moved to the Rochester area from Pennsylvania. He is married.
What is the level of history?
GENERAL APPEARANCE: Healthy appearing individual in no distress
ABDOMEN: Soft, non-tender, without masses. No CVA tenderness
VULVA/LABIA MAJORA: No erythema, ulcerations, swelling, or lesions seen.
BARTHOLIN GLANDS: No cysts, abscesses, induration, discharge, masses, or inflammation noted.
SKENE'S: No cysts, abscesses, induration, discharge, masses, or inflammation noted.
CLITORIS/LABIA MINORA: Clitoris normal. No atrophy, adhesions, erythema, or vesicles noted. Labia unremarkable.
URETHRAL MEATUS: Meatus appears normal in size and location. No masses, lesions or prolapse.
URETHRA: No masses, tenderness or scarring.
BLADDER: Without fullness, masses or tenderness.
VAGINA: Mucosa clear without lesions, Pelvic support normal. No discharge.
CERVIX: The cervix is clear, firm and closed. No visible lesions. No abnormal discharge.
UTERUS: Uterus non-tender and of normal size, shape and consistency. Position and mobility are normal.
ADNEXA/PARAMETRIA: No masses or tenderness noted.
Based on the 1995 documentation guidelines, what is the level of exam?