I-Human Case Study: Thomas Warren, a 72- year-old male, presents with a complaint of an unusual mole

@PROFDOCDIGITALLIBRARIES




I-Human Case Study:
Thomas Warren, a 72-
year-old male,
PR

presents with a
O

complaint of an
FD

unusual mole.
O
C

-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
I-Human Case Study: Thomas Warren, a 72-year-old male, presents with a complaint of an unusual
mole.

,@PROFDOCDIGITALLIBRARIES



(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
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Interventions: No previous treatments or
evaluations.Past Medical History
(PMH):Hypertension (well-controlled with
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medication).Hyperlipidemia.Type 2 Diabetes
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Mellitus.Osteoarthritis.No history of skin cancer or
previous skin lesions of
concern.Medications:Lisinopril 20 mg
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daily.Atorvastatin 40 mg daily.Metformin 500 mg
twice daily.Ibuprofen 200 mg as needed for arthritis
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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.

,@PROFDOCDIGITALLIBRARIES



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,
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occasional itching. No other skin changes or
lesions.HEENT: No headaches, vision changes,
hearing loss, or sore throat.Cardiovascular: No chest
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pain, palpitations, or edema.Respiratory: No cough,
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shortness of breath, or wheezing.Gastrointestinal:
No nausea, vomiting, abdominal pain, or changes in
bowel habits.Genitourinary: No dysuria, frequency,
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or hematuria.Musculoskeletal: Chronic joint pain
due to osteoarthritis, no new joint pain or
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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 mmHgHeart Rate: 76 beats per
minuteRespiratory Rate: 16 breaths per

I-Human Case Study: Thomas Warren, a 72-year-old male, presents with a complaint of an unusual
mole.

, @PROFDOCDIGITALLIBRARIES



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
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lesions or abnormalities noted.Cardiovascular:
Regular rate and rhythm, no murmurs, rubs, or
gallops.Respiratory: Clear to auscultation bilaterally,
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no wheezes, rales, or rhonchi.Gastrointestinal: Soft,
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non-tender, no
hepatosplenomegaly.Musculoskeletal: Normal range
of motion, no acute joint swelling or
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deformities.Neurological: No focal deficits, cranial
nerves II-XII intact.Diagnostic Tests:
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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
I-Human Case Study: Thomas Warren, a 72-year-old male, presents with a complaint of an unusual
mole.