I-Human Case Study: Thomas Warren, a 72- year-old male CASE STUDY EXAM WITH COMPLETE SOLUTION 2024

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 mmHg Heart Rate: 76 beats per minute
Respiratory Rate: 16 breaths per minute Temperature: 98.6°F (37°C)
Oxygen Saturation: 98% on room air
Physical 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:
Dermatoscopy: Shows irregular pigment network, asymmetry, and multiple colors. Skin Biopsy:
Excisional biopsy performed for histopathological examination.
Assessment:
Primary Diagnosis:
Suspicious mole on 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 exposure. Monitoring:
Monitor wound healing post-biopsy.
Assess for any new or changing skin lesions at follow-up appointments. Step-by-step explanation
I-Human Case Study: Thomas Warren, 72 Years Old
Chief 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, an