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Family Medicine 16: 68-Year-Old Male with Skin Lesion
Ali Junayed
United States University
FNP-591
Prof. Tamika Dowling
January 2024
68-Year-Old Male with Skin Lesion
Mr. Harold Fitzgerald, a 68-year-old presented with a red, slightly itchy spot on his left arm that he has had for three to four years, and it has gotten bigger recently. The spot looks like an erythematous, oval patch with ill-defined edges, measuring 35 by 25 millimeters. Mr. Fitzgerald has had seizures before, had a splenectomy, and is having some trouble urinating. The doctor checked him out thoroughly, thought about different possibilities, and then did a punch biopsy to understand the issue better.
Main Diagnosis with Supporting Rationale
The main diagnosis for Mr. Harold Fitzgerald is squamous-cell carcinoma in situ (Bowen disease).
Rationale
Mr. Harold presented with an erythematous, itchy oval patch that has been slowly growing for three to four years. According to Zhang et al. (2023), the signs and symptoms shown by the patient are indicative of squamous cell carcinoma because it presents itself as an erythematous, slowly growing lesion with indefinite borders (Zhang et al., 2023). The results from a biopsy showed it is a type of skin cancer called squamous cell carcinoma in situ which can be healed by a punch biopsy (Zhang et al., 2023).
Two Additional Differential Diagnoses
Actinic Keratosis
Actinic keratosis is a skin problem caused when a person has increased sun exposure. It presents itself as red patches (Davis, 2020). But for Mr. Fitzgerald’s case, this skin condition was ruled out because the lesion he presented with was itchy and slowly progressive. Additionally, the biopsy results claimed it to be squamous cell carcinoma in situ, which is more advanced than regular sun problems (Davis, 2020).
Eczema (Dermatitis)
Eczema is a skin problem with red and itchy patches, but in this case, it is not likely. The continuous nature, growing size, and no signs of contact with harsh substances or past eczema-like issues make eczema less probable. Additionally, the histopathological findings of squamous-cell carcinoma in situ ruled out eczema as the primary diagnosis (Eichenfield et al., 2022).
Diagnostic Plan
Incisional Biopsy or Punch Biopsy
Given the clinical presentation of a progressively enlarging erythematous patch on Mr. Fitzgerald’s left forearm and the need to confirm the nature of the lesion, performing an incisional biopsy or punch biopsy is essential. This will provide a tissue sample for histopathological examination, allowing for an accurate diagnosis of the skin lesion. The biopsy results can guide further management and treatment decisions (Hae Eun Park et al., 2022).
Dermatological Imaging
In some cases, dermatological imaging techniques such as dermatoscopy or imaging studies may be considered to gather additional information about the lesion’s characteristics. However, the primary diagnostic tool remains the biopsy. Imaging could be considered if there is uncertainty or complexity in the clinical presentation (Hae Eun Park et al., 2022).
Follow-Up Dermatological Examination
Following the initial biopsy, a close follow-up dermatological examination is necessary to monitor the progression of the lesion, assess treatment response, and identify any new developments. Regular monitoring is crucial in the management of skin conditions (Hae Eun Park et al., 2022).
Treatment Plan
Wide Excision
Surgical excision is a common treatment for squamous-cell carcinoma in situ. A wide excision involves removing the cancerous lesion along with a margin of normal tissue to ensure complete eradication. This procedure is typically performed under local anesthesia (Biao et al., 2022).
Topical 5-Fluorouracil (5-FU)
In some cases, topical treatments like 5-fluorouracil may be considered. However, whether these topical ointments must be applied on the skin depends on factors such as the size of the lesion, its location, and the patient’s needs. The ointment should be put on the affected area once a day in the evening for 3 to 4 weeks (Biao et al., 2022). To make sure it works well and does not cause problems, the patient should wash the area with mild soap and water before putting on the ointment (Biao et al., 2022).
Education and Counselling
Mr. Fitzgerald needs to be aware of the medicine’s possible side effects like skin irritation. He needs to shield his skin from the sun by wearing protective clothes, and big hats, and using sunscreen with enough sun protection. Also, he should learn to check his skin regularly for any changes or issues so we can catch them early (Biao et al., 2022).
Follow-Up Dermatological Examination
It is important to have regular check-ups to see how the treatment is working, check how the wound is healing, and see any signs of the problem coming back (Biao et al., 2022).
Conclusion
Mr. Harold Fitzgerald’s situation showed how important it is to carefully look at and understand squamous-cell carcinoma in situ (Bowen disease). By doing tests, closely examining the issue, and thinking about other possibilities, one could reach the appropriate diagnosis. The treatment plan includes using a cream called 5-fluorouracil (5-FU), advising on protecting against the sun, and checking his skin regularly.
References
Biao, T., Cai-feng, H., Xiao-hong, L., Xiao-li, C., Wen-bei, L., Jun, W., Chao, C., & Tao, Y. (2022). From Bowen disease to cutaneous squamous cell carcinoma: Eight markers were verified from transcriptomic and proteomic analyses. Journal of Translational Medicine, 20(1). https://doi.org/10.1186/s12967-022-03622-1
Davis, K. E. (2020). Skin cancer, back to basics. Journal of the Dermatology Nurses’ Association, 12(6), 278–285. https://doi.org/10.1097/jdn.0000000000000576
Eichenfield, L. F., Stripling, S., Fung, S., Cha, A., O’Brien, A., & Schachner, L. A. (2022). Recent developments and advances in atopic dermatitis: A focus on epidemiology, pathophysiology, and treatment in the pediatric setting. Pediatric Drugs, 24(4), 293–305. https://doi.org/10.1007/s40272-022-00499-x
Zhang, C., Jiang, B., Zhang, K., Wu, J., Huang, C., Xu, N., Ye, T., Chen, B., Yu, B., Zou, Y., & Shen, C. (2023). Clinical and histopathological characteristics, diagnosis and treatment, and comorbidities of Bowen’s disease: A retrospective study. Frontiers in Medicine, 10. https://doi.org/10.3389/fmed.2023.1281540
If you are looking the week 2 assignment of this class visit: FNP 591 Week 2 Aquifer Case Study: Family Medicine
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