Lataille.Week5.SOAP - J.M 58yo M S CC mole HPI Wife sent the patient in to have a mole looked at on his back Patient has multiple moles and freckles he

Lataille.Week5.SOAP - J.M 58yo M S CC mole HPI Wife sent...

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J.M., 58yo, M.S.CC-moleHPI-Wife sent the patient in to have a mole looked at on his back. Patient has multiple moles and freckles he states, he's had all his life. Wife says the mole on his back looks different than theothers and is growing. Jimmy states he does not use sunscreen, states he sweats it off, and it makes his hands slick. He states that he often takes off his shirt when on the roof, used to get sunburned all the time. “Now my skin is like leather.” Denies any red, scaly, or crusted areas thatdo not heal.PMH-Reports general health as great, "never gets sick"Childhood illnesses-chicken poxSurgeries-noneImmunizations-Does not receive the flu shot, last Tdap 2000Allergies- sulfa drugs- hivesCurrent Medications-NoneSocial Hx- Married for 25 years, works as a roofer, does not exercise. Drinks 1-2 beers most nights of the week. Smokes 1 1/2 ppd, smoking since age 12. Denies illicit drugs. Sleeps 6 hours per night.Family Hx-Parents are alive, both parents have high blood pressure, mother has diabetes. Siblings x 2 with hypertension. Two children ages 22 and 24 in good health.O.PE: Height: 5 feet 10 inches, weight 200 pounds BMI (28.7) OverweightVS BP 160/92, recheck 160/94. T 98.7, P 75, R 18General: Caucasian male, appears stated age in NAD, alert, oriented, and cooperative.Pain: 0/5Skin: Skin warm, dry, and intact. Physical exam: Freckles and numerous nevi noted to face, chest, back, and arms. Asymmetrical lesion with irregular border noted on right shoulder with a diameter of 8 mm. The lesion is black and purple and slightly raised.HEENT: Head normocephalic. Hair thick and distribution even throughout scalp.Eyes: Sclera clear. Conjunctiva: white.
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Neck supple. Mild cervical lymphadenopathy or tenderness noted. Thyroid midline, small, and firm without palpable masses.Lungs: Lungs clear to auscultation bilaterally. Respirations unlaboredCV: Heart S1 and S2 noted, RRR, no murmurs, noted. Peripheral pulses equally bilaterallyA.Primary Diagnosis:Melanocytic nevi of right upper limb, including shoulder (D22.6) – melanoma is a deadly cancerous lesion with asymmetry and irregularity of the borders, variation of the pigment (red, white, blue, gray, black), and increasing in size. These lesions may be raised or superficial.
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