Fitzgerald Year Male Explained for Students (Easy Guide)
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Original Question
Mr. Fitzgerald, a 68-year-old male and you note that he has a lesion on the left forearm, the lesion is erythematous. the skin over the lesion does not feel raised to you, you decide you would call it either a macule (if it is smaller than one centimeter), or a patch (if it is larger than one centimeter). You estimate it is larger than one centimeter, and determine it is a “patch.” Past medical history: Seizure disorder diagnosed about 20 years ago. Takes carbamazepine. Surgical history: Splenectomy done about 15 years ago because he fell from a ladder and injured his spleen. Family history: He reports no family history of skin cancers. Social history: He is divorced and lives by himself, but is thinking about dating someone. He states that he does not smoke and stopped drinking alcohol about 10 years ago. He says that he used to be a heavy drinker. He retired from work as a bricklayer for more than 30 years. He used to bike about 50 to 60 miles a week until his hip bothered him too much. He babysits for his daughter’s kids on the weekend, and he walks once daily. Review of systems: Decreased stream and dribbling of urine for the past four to five months, but reports no chest pain, shortness of breath, or headaches. Slight right hip pain. Vital signs: Temperature is 36.8 °C (98.2 °F) Pulse is 64 beats/minute Respiratory rate is 18 breaths/minute Blood pressure is 124/76 mmHg Head, eyes, ears, nose, and throat (HEENT): Unremarkable. Cardiovascular: Regular heart rhythm without a murmur. Respiratory: Lungs clear to auscultation and percussion. Abdominal: Well-healed linear scar on his left upper quadrant. Skin: Entire skin examined from head to toe, including his scalp, soles, and palms. Left forearm oval erythematous patch measures 35 X 25 mm. POSIBLE DIAGNOSIS: Actinic keratosis , Basal cell carcinoma of the skin, Eczema (dermatitis), Fungal skin infection ,Melanoma, Squamous cell carcinoma of the skin. Differential Dianosis: Lichen planus, Psoriasis, Seborrheic Keratosis. The best next step and test to manage Mr. Fitzgerald’s skin lesion is: Incisional biopsy or punch biopsy. Pathology report of the punch biopsy: Squamous-cell carcinoma in-situ (Bowen disease). Surgical excision is the best option for Mr. Fitzgerald’s lesion. Topical treatments and radiation destroy the malignant cells. However they do not offer the opportunity to examine the margins of the tissue to confirm complete eradication of malignant tissue. In contrast, Mohs microscopic surgery is more extensive than what Mr. Fitzgerald’s lesion requires, as his lesion is relatively low risk in a cosmetically insignificant area, so there’s no reason to be overly careful about sparing tissue in this region, and a wide excision should suffice. You are required to answer all the DISCUSSION QUESTIONS listed below in each domain. DOMAIN: HISTORY 1a) Identify two (2) additional questions that were not asked in the case study and should have been? 1b) Explain your rationale for asking these two additional questions. 1c) Describe what the two (2) additional questions might reveal about the patient’s health. DOMAIN: PHYSICAL EXAM For each system examined in this case; 2a) Explain the reason the provider examined each system. 2b) Describe how the exam findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient’s age, describe what exam findings could be abnormal. 2c) Describe the normal findings for each system. 2d) Identify the various diagnostic instruments you would need to use to examine this patient. DOMAIN: ASSESSMENT (Medical Diagnosis) Discuss the pathophysiology of the: 3a) Diagnosis and, 3b) Each Differential Diagnosis 3c) If it is a Wellness, type ‘Not Applicable’ DOMAIN: LABORATORY & DIAGNOSTIC TESTS Discuss the following: 4a) What labs should be ordered in the case? 4b) Discuss what lab results would be abnormal. 4c) Discuss what the abnormal lab values indicate. References: Alam M, Ratner D. Cutaneous squamous-cell carcinoma. N Engl J Med. 2001;344(13):975-83. Bowen GM, White GL Jr, Gerwels JW. Mohs micrographic surgery. Am Fam Physician. 2005;72(5):845-8. Stulberg DL, Crandell B, Fawcett RS. Diagnosis and treatment of basal cell and squamous cell carcinomas. Am Fam Physician. 2004;70(8):1481-8. Work Group; Invited Reviewers, Kim JYS, et al. Guidelines of care for the management of cutaneous squamous cell carcinoma. J Am Acad Dermatol. 2018;78(3):560-78.
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