ASSESSMENT & PLAN · BY PROBLEM
1. Seborrheic keratosis (L82.1)
Right upper back, 8 mm, well-demarcated waxy brown plaque with a stuck-on appearance. Stable by patient report. Reassurance given; no treatment.
2. Actinic keratosis (L57.0)
Three lesions on the left dorsal forearm, 3–5 mm, erythematous with gritty scale. Cryotherapy applied, two freeze–thaw cycles per lesion.
3. Melanocytic lesion of concern, left shoulder
6 mm, asymmetric, irregular border, two shades of brown. Shave biopsy performed under local anesthetic; hemostasis achieved. Specimen sent for histopathology.
ICD-10 L82.1 · L57.0Procedure documented · Specimen logged to custom field