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WEEK #2 I-HUMAN CASE CLASS 6531:72-YEAR-
OLD MALE PATIENT REASON FOR
ENCOUNTER;UNUSUAL MOLE LOCATION
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WEEK #2 I-HUMAN CASE CLASS 6531:72-YEAR-
OLD MALE PATIENT REASON FOR
ENCOUNTER;UNUSUAL MOLE LOCATION
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WEEK #2 I-HUMAN CASE CLASS 6531:72-YEAR-
OLD MALE PATIENT REASON FOR
ENCOUNTER;UNUSUAL MOLE LOCATION
-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
(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.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 wellmanaged, no new symptoms of hyperglycemia or
hypoglycemia.Objective:Vital Signs:Blood Pressure:
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WEEK #2 I-HUMAN CASE CLASS 6531:72-YEAR-
OLD MALE PATIENT REASON FOR
ENCOUNTER;UNUSUAL MOLE LOCATION
130/80 mmHgHeart Rate: 76 beats per minuteRespiratory Rate: 16 breaths per 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
Diagnosis:Suspicious moleon the back suggestive of malignant melanoma based on ABCDE criteria
(Asymmetry, Border irregularity, Color variation,
Diameter >6mm, Evolution).Differential Diagnoses:Benign melanocytic nevus.Dysplastic
nevus.Seborrheic keratosis.Plan:Immediate Plan:Surgical: Complete excisional biopsy of the mole
performed.Laboratory: Send biopsy for histopathological analysis to confirm
diagnosis.Further Management:Referral: Referral to a dermatologist and oncologist if biopsy
confirms melanoma.Follow-Up: Schedule follow-up appointment to discuss biopsy results and
further management.Patient Education:Educate the patient on the importance of regular skin checks
and protection against UV radiation.Advise on the signs of skin changes that need immediate
medical attention.Preventive Measures:Recommend using broad-spectrum sunscreen with an SPF of
at least 30.Encourage wearing protective clothing and avoiding peak sun
WEEK #2 I-HUMAN CASE CLASS 6531:72-YEAR-
OLD MALE PATIENT REASON FOR
ENCOUNTER;UNUSUAL MOLE LOCATION
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WEEK #2 I-HUMAN CASE CLASS 6531:72-YEAR-
OLD MALE PATIENT REASON FOR
ENCOUNTER;UNUSUAL MOLE LOCATION
,3|Page
WEEK #2 I-HUMAN CASE CLASS 6531:72-YEAR-
OLD MALE PATIENT REASON FOR
ENCOUNTER;UNUSUAL MOLE LOCATION
-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
(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.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 wellmanaged, no new symptoms of hyperglycemia or
hypoglycemia.Objective:Vital Signs:Blood Pressure:
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WEEK #2 I-HUMAN CASE CLASS 6531:72-YEAR-
OLD MALE PATIENT REASON FOR
ENCOUNTER;UNUSUAL MOLE LOCATION
130/80 mmHgHeart Rate: 76 beats per minuteRespiratory Rate: 16 breaths per 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
Diagnosis:Suspicious moleon the back suggestive of malignant melanoma based on ABCDE criteria
(Asymmetry, Border irregularity, Color variation,
Diameter >6mm, Evolution).Differential Diagnoses:Benign melanocytic nevus.Dysplastic
nevus.Seborrheic keratosis.Plan:Immediate Plan:Surgical: Complete excisional biopsy of the mole
performed.Laboratory: Send biopsy for histopathological analysis to confirm
diagnosis.Further Management:Referral: Referral to a dermatologist and oncologist if biopsy
confirms melanoma.Follow-Up: Schedule follow-up appointment to discuss biopsy results and
further management.Patient Education:Educate the patient on the importance of regular skin checks
and protection against UV radiation.Advise on the signs of skin changes that need immediate
medical attention.Preventive Measures:Recommend using broad-spectrum sunscreen with an SPF of
at least 30.Encourage wearing protective clothing and avoiding peak sun
