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.
,(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-Human Case Study: Thomas Warren, a 72-year-old
male, presents with a complaint of an unusual
mole.Non-smoker.Occasional alcohol use (1-2 drinks
per week).No history of recreational drug
use.Limited sun exposure in the past due to indoor
occupation, uses sunscreen occasionally.Review of
Systems (ROS):General:No weight loss, fever, or
fatigue.Skin: Reports the mole on the back,
occasional itching. No other skin changes or
lesions.HEENT: No headaches, vision changes,
hearing loss, or sore throat.Cardiovascular: No chest
pain, palpitations, or edema.Respiratory: No cough,
shortness of breath, or wheezing.Gastrointestinal:
No nausea, vomiting, abdominal pain, or changes in
bowel habits.Genitourinary: No dysuria, frequency,
or hematuria.Musculoskeletal: Chronic joint pain
due to osteoarthritis, no new joint pain or
swelling.Neurological: No dizziness, syncope, or
focal neurological deficits.Endocrine: Diabetes well-
managed, no new symptoms of hyperglycemia or
hypoglycemia.Objective:Vital Signs:Blood Pressure:
130/80 mmHgHeart Rate: 76 beats per
minuteRespiratory Rate: 16 breaths per
I-Human Case Study: Thomas Warren, a 72-year-old male, presents with a complaint of an unusual
mole.
, minuteTemperature: 98.6°F (37°C)Oxygen
Saturation: 98% on room airPhysical
Examination:General: Alert, oriented, and in no
acute distress.Skin: A single mole on the mid-back,
approximately 1.5 cm in diameter, asymmetrical
with irregular borders, variegated color (tan, brown,
and black areas), slightly raised, and no ulceration
or bleeding.HEENT: Normocephalic, atraumatic, no
lesions or abnormalities noted.Cardiovascular:
Regular rate and rhythm, no murmurs, rubs, or
gallops.Respiratory: Clear to auscultation bilaterally,
no wheezes, rales, or rhonchi.Gastrointestinal: Soft,
non-tender, no
hepatosplenomegaly.Musculoskeletal: Normal range
of motion, no acute joint swelling or
deformities.Neurological: No focal deficits, cranial
nerves II-XII intact.Diagnostic Tests:
I-Human Case Study: Thomas Warren, a 72-year-old
male, presents with a complaint of an unusual
mole.Dermatoscopy: Shows irregular pigment
network, asymmetry, and multiple colors.Skin
Biopsy: Excisional biopsy performed for
histopathological examination.Assessment:Primary
I-Human Case Study: Thomas Warren, a 72-year-old male, presents with a complaint of an unusual
mole.