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Describing a lesion

if you do not know anything about the patient and you are describing a lesion based on a photo, how do you describe the history of the lesion?



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4 Answers

I’m not sure you really can, unless you write down what you would potentially ask the patient. Such as how long the lesion has been present, if it comes and goes, etc.

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My teachers would give us a photo and we too had to write a hx. We would just make it up though because it was a chart note exercise and they wanted us to remember to “ask” the patient.

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This is what I did:
Red, approximately 3-4 mm, smooth, diffused patch, (erthroplakia), on the attached gingiva. History questions would be: Does anyone else in your family have this? How long has it been there, is it recurring? Check medications and allergies and medical history.

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Based on what the picture looks like you can deduce what type of questions you would ask the “patient” regarding its history. You can make educated guesses on what you think the history might be but you can’t know for sure from just a picture.

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