lOMoARcPSD| 45010774
I Human Case Study 72 Year Old Male Reason For
Encounter: “Unusual Mole On Shoulder” Latest
Study Case New!!!!
T.W. I Human SOAP Note
Age: 72 y/o
Sex: M
Caucasian
S.
CC “Unusual mole on shoulder”
HPI: T.W. is a 72-year-old Caucasian male who presented with an unusual mole on his shoulder
which he noticed 3-4 months ago. Pt presents with a scaly dark brown mole (which has stayed
the same color) on his shoulder which has persistently grown in size, is irregularly shaped, with
periods of itchiness and has been getting caught on his clothing. No aggravating or alleviating
factors were reported, and no medications or treatments were prescribed for the presented issue.
No associated symptoms presented, denies any fever, chills, SOB, weight loss, night sweats,
other concerning lesions, bleeding, oozing, n/v, or pain in the area of the mole. On examination,
Fitzpatrick type Il skin, on the right shoulder was noted as dull, waxy appearing 4mm dark
brown skin lesion, asymmetric, elevated with irregular borders, rough/scaly upon palpation
without bleeding or discharge. Dermatoscopy shows fissures, ridges, and comedo tie openings:
multiple freckles and small moles over the shoulders, chest, and arms, and scattered over the
back. Vitals signs within normal range. PMH of Osteoarthritis, Hypertension, Hyperlipidemia,
and COPD with an 80-pack-year smoking history. Pt was a farmer, who was often exposed to the
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sun, dust, mold, fertilizer, machinery, dirty clothing, as well as unusual substances. Family
history of lung cancer, with no known history of skin cancer.
Current Medications:
• Lisinopril 20mg 1 tab PO daily for hypertension,
• Atorvastatin 10mg 1 tab PO daily for hyperlipidemia
• Diclofenac gel 1% 2 g TOP 4 times daily as needed for pain in hands, max dose 8 g daily
total for both hands.
• Formoterol/glycoperronium MDI 4.8/9 mcg 2 inhalations twice daily Albuterol MDI 90
mcg 1-2 puffs q 4-6 hrs PRN breathlessness.
Allergies: no known allergies to medication
PMHx: Osteoarthritis in hands, hypertension, hyperlipidemia, COPD.
Surgical: Bilateral total knee arthroplasty 7 years ago
Immunizations are up to date. Flu vaccine this season and had two COVID vaccines but no
boosters. The last pneumococcal shot was at age 66 and the Tetanus shot was 7 years ago.
Soc Hx:
Retired Farmer, who was often exposed to the sun, dust, mold, fertilizer, machinery, dirty
clothing, as well as unusual substances.
Married: Lives with wife
Children: one daughter, healthy
