Patient Name: Harold Fitzgerald
- Age: 68
- Sex assigned at birth: male
Compliant:
Can you tell me what brought you here today?”
“Well, I have had this red spot on my left arm for a while and it is slightly itchy and my daughter urged me to come and see Dr. Hill.”
“How long have you had this spot?”
“I am not really sure, but it has been there a few years, maybe three or four years, and it seems to be growing a little bit recently.”
“Have you hurt your arm or come in contact with potentially caustic materials where the spot is?”
“No.”
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: Mr. Fitzgerlad is divorced and lives by himself, but is thinking about dating someone. He has not been sexually active for 2 years. He states that he does not smoke and stopped drinking alcohol about 10 years ago. He used to be a heavy drinker. He retired from work as a bricklayer more than 30 years ago. Used to bike about 50 to 60 miles a week until his hip bothered him too much; now he walks once daily and babysits for his daughter’s kids on the weekend.
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 scaly erythematous patch with indistinct borders measures 35 X 25 mm.
Mr. Fitzgerald is a 68-year-old previously healthy male with a history of significant sun exposure who presents with a progressively enlarging 35 x 25 mm erythematous, pruritic, oval patch with indistinct borders on his left forearm that has been present for three to four years.
The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:
- Epidemiology and risk factors: 68-year-old previously healthy man, history of significant sun exposure.
- Key clinical findings about the present illness using qualifying adjectives and descriptive language:
- Pruritic, erythematous, oval 35 x 25 mm patch on left forearm
- Chronic and progressively enlarging
| Incisional / punch biopsy | Incisional biopsy means taking out a part of the skin lesion Punch biopsy is a specific incisional biopsy using a cylindrical dermal biopsy tool. |
Pathology report of the punch biopsy: Squamous-cell carcinoma in-situ (Bowen disease).
Expectations
Essay APA format
- Brief introduction of case study
- Identification of the main diagnosis with supporting rationale
- Identification of at least two additional differential diagnoses with brief rationale for why these were ruled out.
- Diagnostic plan with supporting rationale or references
- A specific treatment plan supported by recent clinical guidelines.
- Length: A 750 words, not including references and title page
- Citations: At least one high-level scholarly reference in APA format from within the last 5 years
Grading RURBIC
Identifies main diagnosis with rationale: Identifies main diagnosis and rationale for selection based on cues, problem statement, history and physical findings from the case. The main diagnosis is supported by clinical guidelines or peer-reviewed references.
Two differential diagnoses in addition to main diagnosis: Clearly identifies two differential diagnoses for patient presentation with brief rationale for not being main diagnosis. Rationale is supported with clinical guidelines or peer-reviewed references.
Diagnostic Plan: Identifies the lab, radiology, or other tests needed for the main diagnosis based on most recent clinical practice guidelines or peer reviewed resources. Did not include excessive or non-pertinent tests.
Treatment Plan: Lists the elements of an initial treatment plan for the main diagnosis. Includes medication name, dosage and frequency; patient/family education; appropriate follow up plan; and hospitalizations and consults when appropriate based on appropriate clinical practice guidelines.
Peer reviewed references and clinical guidelines: The student uses at least TWO published clinical guidelines or evidence from peer reviewed professional journals that are not textbooks. The student uses primary sources (the guidelines themselves or the original published work). The chosen supportive literature is written for providers and was published in the last 5 years, or last 10 years if the guideline has not been updated.