,
,Patient Information
Name: Not specified (referred to as “John Smith” for clarity, per
iHuman convention)
Age: 72 years old
Gender: Male
Height: 5’10” (178 cm, average for elderly males)
Weight: 165 lbs (75 kg, BMI 23.7 kg/m², normal)
Reason for Encounter: Unusual mole for 3 months
Setting: Outpatient clinic with laboratory capabilities
Class: 6531, Week #2, Walden University
Date and Time: July 17, 2025, 11:35 AM
History of Present Illness (HPI)
John Smith, a 72-year-old Caucasian male, presents to the outpatient
clinic with a 3-month history of an unusual mole on his right upper
back. He describes the mole as a dark, asymmetrical lesion,
approximately 8 mm in diameter, with irregular borders, variegated
colors (light brown to dark brown-black), and recent changes in size
(increased from ~6 mm) and color (darkening). The mole is mildly itchy
, (3/10 on visual analog scale), with no bleeding, ulceration, pain, or
discharge. His wife noticed the asymmetry and urged evaluation,
prompting the visit. John denies fever, unintentional weight loss, night
sweats, fatigue, or swollen lymph nodes, reducing suspicion for
systemic malignancy or metastasis. He reports a history of significant
sun exposure in his 20s–30s (lifeguard for 5 summers, frequent
sunburns, occasional tanning bed use), increasing skin cancer risk. John
denies recent trauma, new skin products, chemical exposures, or insect
bites at the site.John has a medical history of hypertension (diagnosed
age 55, controlled with lisinopril 20 mg daily) and actinic keratosis
(treated with cryotherapy on face/arms 2 years ago, no recurrence). He
denies personal history of skin cancer but notes his older brother was
diagnosed with melanoma at age 65 (treated successfully). John is a
retired schoolteacher, lives with his wife in a suburban home, and leads
a sedentary lifestyle (walks <1 hour/week, minimal sun exposure now,
uses SPF 30 inconsistently). He denies smoking, uses alcohol socially (1–
2 beers/week), and follows a balanced diet (no recent changes,
adequate fruits/vegetables). John reports mild stress from adjusting to
retirement but no significant psychosocial issues. He has not applied
over-the-counter treatments to the mole and denies other skin changes
or new lesions elsewhere.
,Patient Information
Name: Not specified (referred to as “John Smith” for clarity, per
iHuman convention)
Age: 72 years old
Gender: Male
Height: 5’10” (178 cm, average for elderly males)
Weight: 165 lbs (75 kg, BMI 23.7 kg/m², normal)
Reason for Encounter: Unusual mole for 3 months
Setting: Outpatient clinic with laboratory capabilities
Class: 6531, Week #2, Walden University
Date and Time: July 17, 2025, 11:35 AM
History of Present Illness (HPI)
John Smith, a 72-year-old Caucasian male, presents to the outpatient
clinic with a 3-month history of an unusual mole on his right upper
back. He describes the mole as a dark, asymmetrical lesion,
approximately 8 mm in diameter, with irregular borders, variegated
colors (light brown to dark brown-black), and recent changes in size
(increased from ~6 mm) and color (darkening). The mole is mildly itchy
, (3/10 on visual analog scale), with no bleeding, ulceration, pain, or
discharge. His wife noticed the asymmetry and urged evaluation,
prompting the visit. John denies fever, unintentional weight loss, night
sweats, fatigue, or swollen lymph nodes, reducing suspicion for
systemic malignancy or metastasis. He reports a history of significant
sun exposure in his 20s–30s (lifeguard for 5 summers, frequent
sunburns, occasional tanning bed use), increasing skin cancer risk. John
denies recent trauma, new skin products, chemical exposures, or insect
bites at the site.John has a medical history of hypertension (diagnosed
age 55, controlled with lisinopril 20 mg daily) and actinic keratosis
(treated with cryotherapy on face/arms 2 years ago, no recurrence). He
denies personal history of skin cancer but notes his older brother was
diagnosed with melanoma at age 65 (treated successfully). John is a
retired schoolteacher, lives with his wife in a suburban home, and leads
a sedentary lifestyle (walks <1 hour/week, minimal sun exposure now,
uses SPF 30 inconsistently). He denies smoking, uses alcohol socially (1–
2 beers/week), and follows a balanced diet (no recent changes,
adequate fruits/vegetables). John reports mild stress from adjusting to
retirement but no significant psychosocial issues. He has not applied
over-the-counter treatments to the mole and denies other skin changes
or new lesions elsewhere.
