“5-year-old female with no known PMHx is brought into the office by her father who complaints of strange growths on the daughter’s hands and face for the last 1 month. She pointed to 2 growths on the second digit on her right hand. She also pointed to growths on her face and nose. She denies any pain associated with the growth. She denies any other growths on other locations on her body. She denies any other symptoms such as itching, fever, cold, or vomiting. The child is up to date on her vaccines currently. Father denies that she has any known allergies. The child is not currently on any medications. There are no further complaints currently.”
The case above was a case I presented together with the Journal article for my second site evaluation. It is a case of a young Hispanic female that presented with an unusual growth on her finger, face, and nose (2 papular appearing mass on the 2nd digit of the right hand above the DIP and PIP joints, a similar growth also located on her face near the right eye but medially, and a 0.2 cm raised papular mass over the nasal septum and on the wall of the left nare). During my presentation, I had made the mistake of including the diagnosis (wart) in the HPI and ROS, as opposed to documenting the finding itself as an irregular papular growth. I corrected that in my final submission and made sure to include the suspected diagnosis underneath my differential diagnosis. I also made sure that based on the prior feedback from my first site evaluation not chart “unremarkable” under the ROS but rather to chart the questions I specifically asked and whether or not it was denied under the ROS. Moving forward with my notes I will make sure to avoid making these mistakes again.