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NU514 Spring 2011 – Case Scenario: Skin

Group members: Cornelia Campbell, Emily Caudle, Jessica Chapman, Jill Collins,

Brandy Schnaker, Danelle Shaw, Jonna Voorhees

  1. CASE STUDY HISTORY AND ILLNESS PRESENTATION

Chief Complaint: “One of the moles on my face is changing.”

History of Present Illness:

Mr. C., a 62 year old farmer, comes to the clinic to have an exam about a change in the mole on his face. He just noticed the change 2 weeks ago. He says the mole doesn’t itch, but it has grown larger daily and is darkening. He has not noticed any discharge from the site. He denies being bitten by any insects. Although he works outdoors daily, he does not use sunscreen.

Mr. C has smoked one cigar daily for the past 35 years. On average, he drinks three beers daily and has done so for the past 40 years. He had a broken tibia repaired 2 years ago.

His father died of complications of melanoma. His mother died of lung cancer.

Actual findings on physical examination:

  • Alert older man, resting comfortably on the exam table.
  • BP 110/60 HR=86 and regular Respirations=24 Temp=98.6 F
  • 1cm black, irregularly shaped, slightly elevated lesion on the right forehead.
  • Multiple nevi scattered on the back, abdomen, arms and legs.
  • Numerous capillary hemangiomas on the abdomen.
  • HEAD: normocephalic, atraumatic.
  • Eyes: Pupil’s equal, round, and reactive to light and accommodation, constrict from 6mm to 3mm. Disc margins sharp, fundi without hemorrhages or exudates.
  • External ear canals patent, tympanic membranes with cone of light
  • Oral mucosa pink, dentition in good repair, pharynx without exudates
  • NECK: Supple without thyromegaly no lymphadenopathy
  • THORAX/LUNGS: Thorax symmetric, lungs resonant, breath sounds vesicular.

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  1. IDENTIFY EXAMINATION(S) TO BE PERFORMED AND GIVE RATIONALE FOR EACH SYSTEM

System or
Area Examined / Purpose / Rationale
General Survey /
  1. To get overall idea of patient’s appearance & behavior, emotional stability, cognitive abilities mentation.
  2. To verify chief complaint / primary purpose(s) of visit.
  3. To capitalize on patient education opportunities.
/
  1. Provides information regarding patient’s cognitive, mental and emotional abilities.
  2. Identify patient’s level of self-care and allows general discussion of healthy habits (or the lack of it).
  3. Conversing with patient provides opportunity to explore multiple risk factors.
  4. Improves provider’s understanding of recent signs and symptoms or changes in condition.
  5. Patient may reveal additional information – signs and symptoms which he felt were not related to the CC or insignificant may now be discovered – these may be of interest to the provider & assist in making definitive diagnosis.
  6. Provide multiple teaching opportunities

Vital signs /
  1. Gather objective data regarding patient’s overall general health
/
  1. Serve as real-time indicator of patient’s wellness
  2. Useful to assess for s/s of other disease processes (or to monitor chronic health concerns).

System or
Area Examined / Purpose / Rationale
Skin /
  1. To assess current complaint(s)
  2. To assess other skin areas / lesions not reported by patient.
  3. To assess hard-to reach areas where pt may have been unable to perform self-exam
  4. To assessing ABCDE* of suspicious lesions
/
  1. Provides general idea of extent of skin occurrences.
  2. Assess areas inaccessible for self-examination
  3. Identify any precursor lesions to facilitate early diagnosis and treatment
  4. Identify environmental influences on skin condition.
  5. Patient has family history of malignant melanoma (father died from melanoma associated complications)

Head and Neck including Lymphatic system /
  1. To assess for similar or precursor lesions
  2. To assess lymph nodes for swelling, tenderness
/
  1. Potential area of additional disease process (similar exposure)
  2. Involvement of lymphatic system in metastatic process of malignant lesions (malignant melanoma = rapid progression and metastatic)

Thorax and Lungs /
  1. Patency of airways (ventilation)
  2. Efficacy of respiration
  3. Adventitious breathing sounds
/
  1. Thorax and lungs are often involved in metastatic processes
  2. Patient has family history of lung cancer (mother died of lung cancer)

Cardiovascular /
  1. To assess patency of central and peripheral circulation.
/
  1. In addition to vital signs will provide information regarding patient’s general physiological wellbeing.

Abdomen / 1.To assess for Hepatomegaly, masses & absence of bowel sounds / 2.Indicative of metastatic processes or other chronic health concerns
Breast & Axillae /
  1. Lymphadenopathy
/
  1. Masses in breast and surrounding tissues may be presentation of malignancy

Musculoskeletal and Nervous system /
  1. To assess for any abnormalities
/
  1. Metastasis could affect these systems

Note: ABCDE = Asymmetry, Borders, Color, Diameter, Evolution/Elevation (Fitzpatrick p. 310)

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  1. IDENTIFY PHYSICAL FINDINGS TO HELP DETERMINE DIAGNOSIS

System or
Area Examined / What are we looking for to determine the diagnosis?
General Survey /
  1. Patient’s report of patterns of sun exposure. Total cumulative sun exposure strongly associated with basal cell and squamous cell carcinoma. Intermittent sun exposure associated with melanomas.
  2. History of blistering sun burns.
  3. Mental status changes, weakness, cachexia may indicate metastatic process in the brain.

Vital signs /
  1. Within normal parameters serves as a measure of general physiological wellness
  2. Exceeding normal parameters indicates the impact of disease processes.

Skin /
  1. Characteristics of mole in question (ABCDE)
  2. Other lesions – atypical mole/dysplastic nevus – associated with increased risk for melanoma.
  3. Texture of skin – leathery skin is indicative of total cumulative sun exposure.
  4. Erythema, inflammation and/or tenderness surrounding mole in question –may indicate dysplastic nevus transforming to melanoma
  5. Complexion / skin phototype providing an idea of possible severity of sunburn (extent of intermittent sun damage)

System or
Area Examined / What are we looking for to determine the diagnosis?
Head, Neck and Lymphatic system /
  1. Color of hair and eyes to determine skin phototype (predisposition for suntan and sunburn which will increase risk for skin cancer).
  2. Oral cavity for lesions which could indicate oral malignancies from smoking.
  3. Lymphadenopathy in head or neck area could be indicative of malignant metastasis through the lymphatic system (sentinel lymph nodes).
  4. Palpable supraclavicular lymph nodes are tell-tale sign of malignancy (Seidel, p.217)
  5. Lymph nodes fixed to surrounding tissues, harder than expected & with asymmetrical involvementare causes for concern (Seidel, p.223, 225)
  6. Older patient with localized, persistent lymphadenopathy without evidence of infection or inflammation possible indication of malignancy (Seidel, p. 229)

Thorax & Lungs /
  1. Abnormal breath sounds, difficulty breathing, poor oxygenation and signs of respiratory insufficiency may be indicative of lung involvement – especially considering patient’s family history of cancer.

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  1. LIST 3 DIFFERENTIAL DIAGNOSES WITH RATIONALE

Based on the information provided, the following differential diagnosesare considered:

  1. Melanoma
  • A: Symmetry/asymmetry – inadequate information given – clinician must assess
  • B: Irregularly shaped lesion
  • C: Color is darkening – now almost black (not stated if color changed uniformly or if variegation occurred).
  • D: size >0.5cm,
  • E: Patient reported evolution/elevation - mole has grown bigger and is slightly elevated
  • Area of concern is located in area often noted to be vulnerable to effects of the sun.
  • Patient has a family history of melanoma
  • Several risk factors exist such as lack of use of sunscreen and an occupation where sun exposure occurs.
  • Diagnosis based on biopsy findings from the lesion.
  • However, melanoma is more often found on skin areas where intermittent sun exposure occurs (e.g. back in men and lower legs in women) (Porth & Matfin, p. 1591)
  1. Seborrheic Keratosis
  • Most common of the benign epithelial tumors
  • Hereditary lesions – do not appear until age 30 and continue to occur over a lifetime,
  • Varying from few scattered lesions to sometimes hundreds in elderly patients
  • Range from small, barely elevated papules to plaques with warty surface and “stuck-on” appearance,
  • Can mimic the look of melanoma
  • Occurs frequently in the age group of the patient.
  • Lesions may be skin-colored, tan, black, verrucous papules/plaques – black pigmented lesions more often found in black Africans, African Americans, deeply pigmented south-east Asians.
  • Large pigmented lesions easily mistaken for pigmented basal cell carcinoma or malignant melanoma
  • Verruca vulgaris is similar in appearance but thrombosed capillaries are present
  1. Pigmented basal cell carcinoma (Fitzpatrick p. 287-293)
  • Most common cancer in humans (Fitzpatrick p. 287) – most common skin cancer in light skinned people (Porth & Matfin, p.1592)
  • Caused by UVB spectrum rays – especially associated with prolonged exposure (total cumulative sun exposure) and heavy sun exposure in youth (sunburns before age 20)
  • Clinically different types (nodular, ulcerating, pigmented, sclerosing and superficial)
  • Locally invasive, aggressive and destructive but slow growing.
  • Very limited (almost none at all) tendency to metastasize
  • Pigmented clinical type: brown to blue or black
  • Smooth, glistening surface
  • Hard or firm
  • May be indistinguishable from superficial spreading or nodular melanoma but is usually harder.
  • Stippled (variegated) pigmentation may be seen
  • Usually isolated lesion (> 90% occurring in face) and appears mostly in “danger sites”
  • medial and lateral canthi, nasolabial fold, behind the ears, sometimes on trunk
  • Has capacity to develop hair follicles
  1. Dysplastic nevus
  • Larger than other nevi (often > 5mm in diameter)
  • Often appear as a flat, slightly raised plaque with a pebbly surface, or a target-like lesion with a darker, raised center and irregular border.
  • Vary in color from brown and red to flesh tones.
  • One person may have hundreds of these lesions – occurring both in sun exposed and covered areas of the body.
  • Documented in multiple members of families prone to develop malignant melanoma – possibility of malignant transformation – especially when changes occur (size, thickness, color, itching and bleeding) (Porth & Matfin, p. 1590).

Appendix A

A B C D (E) of Skin Lesions

Skin Phototype classifications

Skin Phototype / Suntan and Sunburn History
I / Very fair, always burns, never tans, sensitive to sun exposure
Eyes blue or green; hair blonde or red
II / Fair, burns easily, tans minimally
Eyes blue, hazel or brown; hair blond, red or brown
III / Medium; burns moderately, tans gradually to light brown
IV / Olive, burns minimally, always tans well to moderately brown
V / Brown; rarely burns, tans profusely to dark
VI / Black, never burns, deeply pigmented, lease sensitive

Porth & Matfin p. 1583 (adapted from Skin Cancer Foundation, 2007)