Patient Initials: __JM_____                Age: ___43____         Gender: ___Male____


Chief Complaint (CC): (Image 4) JM is a 43-year-old African-American male patient in good health. He presents to the clinic today because of a growth noticed on his lower back.

History of Present Illness (HPI): The patient is a 43-year-old AA male presenting to the healthcare setup with a complaint of a mole on his back noticed by a friend. On assessment the following findings were obtained:

Location: Lower Back

Onset: The growth has been noticed for about six months now.

Character: The growth itches sometimes but it does not hurt.

Associated signs and symptoms: None

Timing: Itching is observed after wearing tight clothing like vests and when lying on the back.

Exacerbating/ relieving factors: Wearing loose clothing and change of sleeping position.

Severity: 1/10 pain rating scale.

Medications: The patient uses Aroma Magic Aloe Vera Sunscreen Gel with SPF of 20 occasionally when he goes for a run and during relaxing hours on the beach.

Allergies: The patient is allergic to eggs. He reports that the problem started during his early adolescence. He experiences stomach pain and skin rashes whenever he takes eggs. No drug allergies noted.

Past Medical History (PMH): The patient was hospitalized in 2009 with a diagnosis of right femur fracture. He was doing practice on the field when he fell and acquired the injury. He was hospitalized for two months and discharged home. Childhood health is clean. He attends health checkups after three months.

Past Surgical History (PSH): No surgeries have been done on the patient.

Personal/Social History: The patient is an athlete, and he does regular exercises. He goes for a morning and evening run every day and spends most of his time training on the field. His diet is mainly made up of greens and fruits. The patient does not drink or smoke. His social life revolves around his career.

Immunization History: All the childhood immunizations are up to date. He received immunization for yellow fever four months ago when he attended an athletic competition in West Africa. The most recent immunization received is tetanus given four weeks ago after sustaining a deep cut on his left ankle.

Significant Family History: He is the second born in a family of three. Mr. JM has a family history of skin cancer; his father had several squamous cell carcinomas removed on his face.

Lifestyle: The patient has a stable lifestyle, lives in his house but does not have a family. He spends much of his time training, and when he is free, he goes out with friends. During the weekends he goes to the beach for windsurfing and basking on the sun.

Review of Systems:

General: The patient is healthy looking, well groomed, oriented to time place and person

HEENT: There are no complaints of a headache, visual impairment, hearing loss, nose problems or a sore throat.

Respiratory: The breathing rate is normal with a breathing rate of 20b/m. Chest expansion and recoil is good. No abnormal breath sounds detected.

Cardiovascular: The heart rate is at 78b/m, and the capillary refill is at 2 seconds. There is no central or peripheral cyanosis.

Gastrointestinal: There is no complaint of nausea and vomiting or swallowing problems noted. The consistency and pattern of the stool are normal.

Genitourinary: No complaints of anuria, dysuria, polyuria or hematuria.

Musculoskeletal: Both the upper and the lower limbs are functional. The range of motion of both limbs is good.

Neurological: Orientation to time, place and person is present.

Psychiatric: No psychiatric history

Skin: The skin color is brown with some warts and nevi on the hands and the lower legs. A skin growth is observed at the back.

Allergic/Immunologic: Patient is allergic to eggs.


Physical Exam:

Vital signs: Temp 36.2 degrees, pulse 78b/m, Resp 20b/m, Bp 118/75mmhg, height 1.7m, weight 68, BMI 23.5.

General:  The patient is healthy looking, well groomed, oriented to time place and person. The posture is straight, displays a labile affect and communicates effectively.

Skin: A complete skin assessment reveals various warts, freckles, and nevi. Except the back growth prompting treatment, the other lesions appear normal. The growth on the back is raised; measures 7mm in diameter and it has irregular borders with nodules on the surface. The growth is red-pink with some signs of impending darkening. The patient confirms that the growth has been increasing in size over the past six months, but it is difficult to note due to its location. The patient is referred to the dermatologist for evaluation. A skin biopsy should be done to detect the exact cause of the growth.

ASSESSMENT:  The priority diagnosis is Melanoma. A skin biopsy will detect the clinical stage of the melanoma.

Differential diagnosis:

Keloid Scar: A Keloid is a scar that grows at the site of injury, and it becomes bigger than normal. They form where the skin is cut, surgical sites and in conditions like acne. The growths are often firm, raised, hard, and grow larger over time (Hay et al., 2015). The color varies from slightly pink to dark, and they are common in dark-skinned individuals

Melanocytic nevi: They are lesions found on the skin, and it can range from a few lesions to hundreds of them on the skin of an individual (Habif, 2015). The nevi are commonly tan to brown and their sizes are usually less than three centimeters, but giant Nevis becomes larger than the normal size. Most Nevi are congenital, but some are caused by environmental factors like ultraviolet rays.

Skin tags: They are small pieces of soft hanging skin that have a stalk. They normally arise where the skin rubs against each other. The common sites for skin tags include the neck, groin, armpits, under the breast and folds of the buttocks (Habif, 2015).

Correct diagnosis: Nodular Melanoma. Melanoma is cancer of the skin which affects the melanocytes. Nodular melanomas are the most common types, and they are associated with the history of sun exposure, family history of skin cancer or moles and white ancestry or fair skin (Garbe et al., 2016). The condition is fatal because it can lead to spread to other body parts if not treated early. The signs and symptoms of nodular melanomas include a faster growth, size greater than six millimeters, rough or warty surfaces, skin pigmentation, and itching. Statistics indicate that one-third of nodular melanomas are not pigmented (Habif., 2015). The diagnosis of nodular melanoma is done through skin biopsy and sometimes trough dermascopy. The description outweighs the other differential diagnoses thus forming the probable diagnosis of the condition.


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