Past medical history: Seizure disorder diagnosed about 20 years ago.

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.

 

HPI:

 

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.

 

DIFFERENTIAL DIAGNOSIS

 

Differential of Erythematous Patch

More likely diagnoses

 

Eczema (dermatitis)

 

Chronic inflammatory skin condition is also known as dermatitis.

Eczema can vary in appearance, commonly appears dry, erythematous, and is often pruritic.

Can occur in any location; frequently occurs on flexural areas.

Squamous cell carcinomas

 

Squamous cell carcinomas are scaly and erythematous but, unlike actinic keratoses, tend to have a raised base.

Lesions may take the form of a patch, plaque, or nodule, sometimes with scaling and/or an ulcerated center.

Borders are often irregular and bleed easily.

Unlike basal cell carcinomas, the heaped-up edges of a squamous cell carcinoma are fleshy rather than clear in appearance.

Squamous cell carcinoma comprises 20 percent of all cases of skin cancer.

History of significant sun exposure is a risk factor for squamous cell carcinoma and it typically occurs on areas of the skin that have been exposed to sunlight for many years, such as the extremities or face.

Actinic keratoses

 

Actinic keratoses are scaly keratotic patches that are often more easily felt than seen.

A history of significant sun exposure is a risk factor for actinic keratosis.

Basal cell carcinomas

 

Basal cell carcinomas may be plaque-like or nodular with a waxy, translucent appearance, often with ulceration and/or telangiectasia.

Usually there is no associated itching or change in skin color, although this can vary.

Basal cell carcinoma is common on the face and on other exposed skin surfaces but may occur anywhere.

Comprising 60 percent of primary skin cancers, basal cell carcinomas are typically slow-growing lesions that invade local tissues but rarely metastasize.

A long history of sun exposure is a risk factor for basal cell carcinoma.

Melanoma

 

In the United States, the median age at diagnosis of melanoma is 53, with about one in four new cases occurring in those younger than 40 years.

Lesions that are growing, spreading, or pigmented, or those that occur on exposed areas of skin, are of particular concern for melanoma.

Although it comprises only 1 percent of all skin cancers, malignant melanoma accounts for over 60 percent of skin cancer deaths.

The lesions of superficial spreading melanoma are dark brown or black.

Slowly spreading irregular outlines in the initial phase. Some areas may be a lighter shade.

Since not all malignant melanomas are visibly pigmented, physicians should be suspicious of any lesion that is growing or that bleeds with minor trauma.

More than half of melanoma in females occurs on the legs.

Sun exposure is a risk factor for melanoma; studies have shown that the prevalence of melanoma increases with proximity to the equator.

Persons with skin types that burn easily and tan with difficulty, with red or blond hair, and with freckles are at higher risk.

Although cumulative sun exposure is linked to nonmelanoma skin cancer, intermittent intense sun exposure seems to be more related to melanoma risk.

Fungal infection

 

Can have an acute, erythematous appearance

ADDITIONAL SYMPTOMS:

“Doctor, I have another question about something totally different. I have to get up during the night several times, maybe two or three times, to go to the bathroom. It takes a long time to start urination. Do I have a prostate condition?”

DIFFFERENTIAL DX: BPH, LOWER UTI,

TX/PLAN:

When evaluating for BPH, perform:

 

Digital rectal exam (DRE) is generally done to assess prostate size and consistency and to detect nodules, indurations, and asymmetry—all of which raise suspicion for malignancy. Rectal sphincter tone should also be determined. DRE is not recommended as screening for prostate cancer.

Urinalysis should be done to detect urinary tract infection and blood, which could indicate bladder cancer or stones.

Serum prostate specific antigen (PSA) level determination is recommended for males with a life expectancy of 10 years or longer and for those whose PSA level may influence BPH treatment. This includes most patients who are considering treatment with a 5-alpha reductase inhibitor. This practice should be distinguished from recommendations about utilizing the PSA as a screening test. In this case, the patient actually has symptoms that could represent prostate cancer; screening is only for asymptomatic individuals.

ADDITIONAL PROBLEM:

 

dry, cracking, erythematous skin between toes – DX: TINEA PEDIS

Past medical history: Seizure disorder diagnosed about 20 years ago.

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