I-Human Case Study: Thomas Warren, a 72 -year-old male, presents with a complaint of an unusual mole . 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, and shape. Subjective: History of Present Illness (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 become itchy occasionally. Associated Symptoms: No bleeding, oozing, or pain. Aggravating Factors: None reported. Relieving Factors: None reported. Previous Interventions: No previous treatments or evaluations. Past Medical History (PMH): Hypertension (well -controlled with medication). Hyperlipidemia. Type 2 Diabetes Mellitus. Osteoarthritis. No history of skin cancer or previous skin lesions of concern. Medications: Lisinopril 20 mg daily. Atorvastatin 40 mg daily. Metformin 500 mg twice daily. Ibuprofen 200 m g as needed for arthritis 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 . 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, 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. Respirat ory: 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, asymmetr ical 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 defic its, cranial nerves II -XII intact. Diagnostic Tests:
