I-Human Case Study: Thomas Warren, a 72-year-old male, presents with a complaint of an unusual
mole.
I-Human Case Study:
Thomas Warren, a 72-
year-old male,
presents with a
complaint of an
unusual mole.
-Human Case Study: Thomas Warren, 72 Years
OldChief Complaint:Thomas Warren, a 72-year-old
male, presents with a complaint of an unusual mole
on his back that he noticed about 3 months ago. He
reports that the mole has changed in size, color, and
shape.Subjective:History of Present Illness
I-Human Case Study: Thomas Warren, a 72-year-old male, presents with a complaint of an unusual
mole.
,I-Human Case Study: Thomas Warren, a 72-year-old male, presents with a complaint of an unusual
mole.
(HPI):Onset: Noticed the mole 3 months
ago.Location: Middle of the back.Duration:
Persistent since first noticed.Characteristics: The
mole has become larger, darker, and has irregular
borders. It has also becomeitchy
occasionally.Associated Symptoms: No bleeding,
oozing, or pain.Aggravating Factors: None
reported.Relieving Factors: None reported.Previous
Interventions: No previous treatments or
evaluations.Past Medical History
(PMH):Hypertension (well-controlled with
medication).Hyperlipidemia.Type 2 Diabetes
Mellitus.Osteoarthritis.No history of skin cancer or
previous skin lesions of
concern.Medications:Lisinopril 20 mg
daily.Atorvastatin 40 mg daily.Metformin 500 mg
twice daily.Ibuprofen 200 mg as needed for arthritis
pain.Allergies:No known drug allergies.Family
History:Father: Deceased at 85, history of coronary
artery disease.Mother: Deceased at 78, history of
hypertension.No family history of skin cancer.Social
History:Retired accountant.Lives with spouse.
I-Human Case Study: Thomas Warren, a 72-year-old male, presents with a complaint of an unusual
mole.
,I-Human0Case0Study:0Thomas0Warren,0a072-year-
old0male,0presents0with0a0complaint0of0an0unusual
mole.
I-Human0Case0Study:0Thomas0Warren,0a072-year-
old0male,0presents0with0a0complaint0of0an0unusual0m
ole.Non-smoker.Occasional0alcohol0use0(1-
20drinks0per0week).No0history0of0recreational0drug0u
se.Limited0sun0exposure0in0the0past0due0to0indoor0o
ccupation,0uses0sunscreen0occasionally.Review0of0Sy
stems0(ROS):General:No0weight0loss,0fever,0or0fatigu
e.Skin:0Reports0the0mole0on0the0back,0occasional0itch
ing.0No0other0skin0changes0or0lesions.HEENT:0No0he
adaches,0vision0changes,0hearing0loss,0or0sore0throat.
Cardiovascular:0No0chest0pain,0palpitations,0or0edem
a.Respiratory:0No0cough,0shortness0of0breath,0or0wh
eezing.Gastrointestinal:0No0nausea,0vomiting,0abdo
minal0pain,0or0changes0in0bowel0habits.Genitourinar
y:0No0dysuria,0frequency,0or0hematuria.Musculoskel
etal:0Chronic0joint0pain0due0to0osteoarthritis,0no0ne
w0joint0pain0or0swelling.Neurological:0No0dizziness,0
syncope,0or0focal0neurological0deficits.Endocrine:0Di
abetes0well-
0managed,0no0new0symptoms0of0hyperglycemia0or0h
ypoglycemia.Objective:Vital0Signs:Blood0Pressure:01
30/800mmHgHeart0Rate:0760beats0per0minuteRespir
atory0Rate:0160breaths0per
I-Human0Case0Study:0Thomas0Warren,0a072-year-
old0male,0presents0with0a0complaint0of0an0unusual
mole.
, I-Human0Case0Study:0Thomas0Warren,0a072-year-
old0male,0presents0with0a0complaint0of0an0unusual
mole.
minuteTemperature:098.6°F0(37°C)Oxygen0Saturatio
n:098%0on0room0airPhysical0Examination:General:0A
lert,0oriented,0and0in0no0acute0distress.Skin:0A0single0
mole0on0the0mid-
back,0approximately01.50cm0in0diameter,0asymmetri
cal0with0irregular0borders,0variegated0color0(tan,0bro
wn,0and0black0areas),0slightly0raised,0and0no0ulcerati
on0or0bleeding.HEENT:0Normocephalic,0atraumatic,0
no0lesions0or0abnormalities0noted.Cardiovascular:0R
egular0rate0and0rhythm,0no0murmurs,0rubs,0or0gallop
s.Respiratory:0Clear0to0auscultation0bilaterally,0no0w
heezes,0rales,0or0rhonchi.Gastrointestinal:0Soft,0non-
tender,0no0hepatosplenomegaly.Musculoskeletal:0No
rmal0range0of0motion,0no0acute0joint0swelling0or0defo
rmities.Neurological:0No0focal0deficits,0cranial0nerve
s0II-XII0intact.Diagnostic0Tests:
I-Human0Case0Study:0Thomas0Warren,0a072-year-
old0male,0presents0with0a0complaint0of0an0unusual0m
ole.Dermatoscopy:0Shows0irregular0pigment0networ
k,0asymmetry,0and0multiple0colors.Skin0Biopsy:0Exci
sional0biopsy0performed0for0histopathological0exam
ination.Assessment:Primary
I-Human0Case0Study:0Thomas0Warren,0a072-year-
old0male,0presents0with0a0complaint0of0an0unusual
mole.
mole.
I-Human Case Study:
Thomas Warren, a 72-
year-old male,
presents with a
complaint of an
unusual mole.
-Human Case Study: Thomas Warren, 72 Years
OldChief Complaint:Thomas Warren, a 72-year-old
male, presents with a complaint of an unusual mole
on his back that he noticed about 3 months ago. He
reports that the mole has changed in size, color, and
shape.Subjective:History of Present Illness
I-Human Case Study: Thomas Warren, a 72-year-old male, presents with a complaint of an unusual
mole.
,I-Human Case Study: Thomas Warren, a 72-year-old male, presents with a complaint of an unusual
mole.
(HPI):Onset: Noticed the mole 3 months
ago.Location: Middle of the back.Duration:
Persistent since first noticed.Characteristics: The
mole has become larger, darker, and has irregular
borders. It has also becomeitchy
occasionally.Associated Symptoms: No bleeding,
oozing, or pain.Aggravating Factors: None
reported.Relieving Factors: None reported.Previous
Interventions: No previous treatments or
evaluations.Past Medical History
(PMH):Hypertension (well-controlled with
medication).Hyperlipidemia.Type 2 Diabetes
Mellitus.Osteoarthritis.No history of skin cancer or
previous skin lesions of
concern.Medications:Lisinopril 20 mg
daily.Atorvastatin 40 mg daily.Metformin 500 mg
twice daily.Ibuprofen 200 mg as needed for arthritis
pain.Allergies:No known drug allergies.Family
History:Father: Deceased at 85, history of coronary
artery disease.Mother: Deceased at 78, history of
hypertension.No family history of skin cancer.Social
History:Retired accountant.Lives with spouse.
I-Human Case Study: Thomas Warren, a 72-year-old male, presents with a complaint of an unusual
mole.
,I-Human0Case0Study:0Thomas0Warren,0a072-year-
old0male,0presents0with0a0complaint0of0an0unusual
mole.
I-Human0Case0Study:0Thomas0Warren,0a072-year-
old0male,0presents0with0a0complaint0of0an0unusual0m
ole.Non-smoker.Occasional0alcohol0use0(1-
20drinks0per0week).No0history0of0recreational0drug0u
se.Limited0sun0exposure0in0the0past0due0to0indoor0o
ccupation,0uses0sunscreen0occasionally.Review0of0Sy
stems0(ROS):General:No0weight0loss,0fever,0or0fatigu
e.Skin:0Reports0the0mole0on0the0back,0occasional0itch
ing.0No0other0skin0changes0or0lesions.HEENT:0No0he
adaches,0vision0changes,0hearing0loss,0or0sore0throat.
Cardiovascular:0No0chest0pain,0palpitations,0or0edem
a.Respiratory:0No0cough,0shortness0of0breath,0or0wh
eezing.Gastrointestinal:0No0nausea,0vomiting,0abdo
minal0pain,0or0changes0in0bowel0habits.Genitourinar
y:0No0dysuria,0frequency,0or0hematuria.Musculoskel
etal:0Chronic0joint0pain0due0to0osteoarthritis,0no0ne
w0joint0pain0or0swelling.Neurological:0No0dizziness,0
syncope,0or0focal0neurological0deficits.Endocrine:0Di
abetes0well-
0managed,0no0new0symptoms0of0hyperglycemia0or0h
ypoglycemia.Objective:Vital0Signs:Blood0Pressure:01
30/800mmHgHeart0Rate:0760beats0per0minuteRespir
atory0Rate:0160breaths0per
I-Human0Case0Study:0Thomas0Warren,0a072-year-
old0male,0presents0with0a0complaint0of0an0unusual
mole.
, I-Human0Case0Study:0Thomas0Warren,0a072-year-
old0male,0presents0with0a0complaint0of0an0unusual
mole.
minuteTemperature:098.6°F0(37°C)Oxygen0Saturatio
n:098%0on0room0airPhysical0Examination:General:0A
lert,0oriented,0and0in0no0acute0distress.Skin:0A0single0
mole0on0the0mid-
back,0approximately01.50cm0in0diameter,0asymmetri
cal0with0irregular0borders,0variegated0color0(tan,0bro
wn,0and0black0areas),0slightly0raised,0and0no0ulcerati
on0or0bleeding.HEENT:0Normocephalic,0atraumatic,0
no0lesions0or0abnormalities0noted.Cardiovascular:0R
egular0rate0and0rhythm,0no0murmurs,0rubs,0or0gallop
s.Respiratory:0Clear0to0auscultation0bilaterally,0no0w
heezes,0rales,0or0rhonchi.Gastrointestinal:0Soft,0non-
tender,0no0hepatosplenomegaly.Musculoskeletal:0No
rmal0range0of0motion,0no0acute0joint0swelling0or0defo
rmities.Neurological:0No0focal0deficits,0cranial0nerve
s0II-XII0intact.Diagnostic0Tests:
I-Human0Case0Study:0Thomas0Warren,0a072-year-
old0male,0presents0with0a0complaint0of0an0unusual0m
ole.Dermatoscopy:0Shows0irregular0pigment0networ
k,0asymmetry,0and0multiple0colors.Skin0Biopsy:0Exci
sional0biopsy0performed0for0histopathological0exam
ination.Assessment:Primary
I-Human0Case0Study:0Thomas0Warren,0a072-year-
old0male,0presents0with0a0complaint0of0an0unusual
mole.
