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
advanced pathophysiology advanced pharmacology ati comprehensive predictor ati exit ati exit exam 2024 version comprehensive retake test ati fundamentals proctored ati rn fundamentals biology computer science computer studies education fundamentals of nursing health care health care/ nursing health care/ nursing/pediatrics health care/ nursing/pharmacology hesi a2 hesi rn exit exam mathematics medical-surgical nursing nclex nursing nutrition pharmacology psychotherapy with multiple modalities