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(Solved) Setting : Small town family practice clinic You've been busy this morning. You pull the chart for your next patient; the chief complaint is a mole....



Setting: Small town family practice clinic

You’ve been busy this morning—. You pull the chart for your next patient; the chief complaint is a mole. You review the chart. You have not met this patient. Sarah M. is 50-years-old and has not been to the office in over a year. Her sister has accompanied her to the visit. 

Last time she was here was a year ago for an annual physical which was otherwise normal.

When you enter the room, you see a woman sitting in the chair. She has light red hair and green eyes. Her skin color is deeply tanned on her face and arms. You ask Sarah what brings her in to see you today. Sarah looks at you blankly for a minute, pauses and then states, “The only reason I’m here is because my sister told me I have to come and have you check a mole on my back. Moles and freckles run in our family. It’s just who we are. I can’t see my back but she says the one on my neck looks different than the others and is growing. She looked it up on the Internet and says it could be cancer. She is always finding strange diseases on the Internet. She made me come, so here I am.”

PMHx: Reports general health as great, “I never get sick.”

Childhood/previous illnesses: chicken pox

Chronic illnesses: None

Surgeries: None

Hospitalizations: None

Immunizations: Does not receive the flu shot, last Tdap 2000.

Allergies: sulfa drugs: hives

Blood transfusions: None

Alcohol: none

Illicit Drugs: none 

Sleeps 10-12 hours/night

Current medications: Black Cohosh- Hot flashes

Social History: Divorced for 15 years, works as a Gardner, does not exercise.

Family History: Parents are alive, both parents have high blood pressure, mother has diabetes and Parkinson’s Disease. Siblings x 2 with hypertension, Atrial Fibrillation. Two children ages 24 and 22 in good health.

Before you begin a review of systems there is a knock on the door. You answer and the patient’s sister pulls you out of the room. She states, “Before you get started I am worried about more than just the mole. Sarah has been sleeping almost 12 hours a night and she usually only sleeps 7-8 hours. She got lost last week on her way to work, a place she has been going to for years. We were at a picnic together over the weekend and my daughter’s shoelace was untied. My arms were full and I asked her to tie the lace for me and she got irritable and made a big deal out of it. She actually didn’t end up tying them. I didn’t think anything of it at the time but when we got home and I noticed her new tennis shoes were Velcro and not lace….I know these are really random situations but she is definitely not herself.”

Click here to see the image of the mole on Sarah's back

 Discussion Questions Part One:

  • List any further questions you have for Sarah and link them to their respective differential diagnoses. 
  • What are the three most common, most likely differential diagnoses for this visit thus far with pathophysiology and evidence-based rationale? Please include the pertinent info from the case study that leads you to consider this diagnosis.
  • Based on your differential diagnosis list, identify what body systems will you examine along with pertinent positive/negatives symptoms you’d be looking for to support or rule out your differential diagnoses.
  • List any relevant labs/diagnostic tests and link them to each diagnosis in the differential list. Remember to include evidence based support for any testing you order along with rationale if you feel no testing is warranted.


 


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