YEAR OLD MALE PRESENTING WITH UNUSUAL MOLE AT
OUTPATIENT CLINIC WITH LABORATORY AND IMAGING
CAPABILITIES
,PATIENT INFORMATION
Name: Albert Walsh
Age: 72 years
Sex: Male
Height: 6′0″ (183 cm)
Weight: 179.0 lb (81.4 kg)
Location: Outpatient clinic with laboratory and imaging capabilities
Reason for Encounter: Unusual mole
Albert Walsh is a 72-year-old male who presents with a changing skin lesion
(unusual mole) on his right shoulder that has evolved over the past several
months, causing irritation and concern for malignancy.
, REASON FOR ENCOUNTER
The patient presents with a pigmented mole that has changed in size, shape,
texture and symptoms over the past 3–4 months. This visit aims to
characterize the lesion, perform a comprehensive dermatologic and systemic
evaluation, develop a clinical differential diagnosis, and initiate appropriate
diagnostic and management steps.
Component Description
Encounter type Outpatient clinic visit
Chief complaint Unusual mole with recent changes
Onset Several months ago
Duration Progressive ~3–4 months
Location Right shoulder
Characteristics Dark brown, irregular borders, scaly, itchy
Aggravating
Contact with clothing
factors
Relieving factors None effective so far
Associated
Occasional itch; no bleeding, no ulceration
symptoms
Systemic concerns No fever, weight loss, night sweats
Determine if lesion is benign or malignant, obtain
Patient goals
diagnosis and appropriate care