Aquifer Case Study
Case Information Required
Complete only the History, Physical Exam, and Assessment sections of the Aquifer case study: Family Medicine 16: 68-year-old male with a skin lesion.
You are required to answer all the DISCUSSION QUESTIONS listed below in each domain.
1a) Identify two (2) additional questions that were not asked in the case study and should have been?
1b) Explain your rationale for asking these two additional questions.
1c) Describe what the two (2) additional questions might reveal about the patient’s health.
DOMAIN: PHYSICAL EXAM
For each system examined in this case;
2a) Explain the reason the provider examined each system.
2b) Describe how the exam findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient’s age, describe what exam findings could be abnormal.
2c) Describe the typical findings for each system.
2d) Identify the various diagnostic instruments you would need to use to examine this patient.
DOMAIN: ASSESSMENT (Medical Diagnosis)
Discuss the pathophysiology of the:
3a) Diagnosis and,
3b) Each Differential Diagnosis
3c) If it is a Wellness, type ‘Not Applicable
DOMAIN: LABORATORY & DIAGNOSTIC TESTS
Discuss the following:
4a) What labs should be ordered in the case?
4b) Discuss what lab results would be abnormal.
4c) Discuss what the abnormal lab values indicate.
4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis.
4e) If this is a wellness visit, discuss what the U.S. Preventive Taskforce recommends for patients in this age group.
Aquifer Case Study Scenario
You are working in a family medicine clinic with Dr. Hill. She asks you to see Mr. Fitzgerald, a 68-year-old male who has been her patient for several years.
Dr. Hill tells you, “I spoke with Mr. Fitzgerald’s daughter at church yesterday. She is a nurse and is very concerned about her father’s skin condition, along with his other medical problems. He was not particularly interested in coming to see me, but his daughter encouraged him to do so.”
She continues, “Before we go in and see Mr. Fitzgerald together, let’s briefly talk about the way to describe skin conditions and the terminology used to describe primary and secondary skin lesions.
You and Dr. Hill enter the exam room. After introducing you to Mr. Fitzgerald, Dr. Hill receives permission from him to let you interview him and then steps out.
You sit down across from Mr. Fitzgerald and ask a few questions:
“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.”
You look at Mr. Fitzgerald’s left forearm to see the lesion he shows you.
Right away you note that the lesion is erythematous. Remembering what Dr. Hill just taught you about dermatology terminology, you run your finger over the lesion. Since the skin over the lesion does not feel raised to you, you decide you would call it either a macule (if it is smaller than one centimeter), or a patch (if it is larger than one centimeter). You estimate it is larger than one centimeter, and determine it is a “patch.”
“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?”
You decide to gather information about the rest of his history.
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 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.
You thank Mr. Fitzgerald for the opportunity to interview him and inform him that you will step out of the room to discuss your findings with Dr. Hill. In the meantime, you instruct Mr. Fitzgerald to change into a gown.
You step out of the exam room and fill Dr. Hill in on what you have discovered so far, including that Mr. Fitzgerald has a 35 x 25 mm oval erythematous patch on his left forearm.
Dr. Hill suggests, “Before we go back to see Mr. Fitzgerald together, let’s talk a little bit more about what else to look for on a skin exam.”
You and Dr. Hill enter the room and perform the physical exam:
- 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.
Dr. Hill instructs Mr. Fitzgerald to get dressed while you both step out of the room.
Dr. Hill asks you, “What do you think are the most important findings so far?
As you reflect on your differential diagnoses, you tell Dr. Hill that even though you are leaning toward the diagnosis of skin cancer (either squamous cell carcinoma, basal cell carcinoma, or melanoma), you have not completely ruled out the possibility that this is either eczema or a fungal skin infection.
“Well, this is a good topic for us to talk about,” Dr. Hill replies. “Suppose we decide this is eczema, how should we treat it?”
“Excellent,” Dr. Hill continues. “What if we decided Mr. Fitzgerald has a fungal infection, how would we treat that? Let’s talk about the basics of antifungal treatment and when to use systemic versus topical antifungal agents.”
“Okay,” Dr. Hill summarizes, “so we’ve talked about how we would treat Mr. Fitzgerald if he has eczema or a fungal infection. Do you think we should treat his skin lesion with an antifungal cream or a corticosteroid cream?”
After you think about this for a moment, you reply, “I’m not really sure. I don’t think we can decide how to treat the lesion until we know the diagnosis.”
You tell Dr. Hill that you think the best option for Mr. Fitzgerald is a punch biopsy. She smiles at you and replies, “Excellent. That was a bit of a trick question. In some cases, if there’s not a good diagnostic procedure, or if there are not huge risks associated with a condition, it is appropriate to treat empirically. However, in this situation, we have a good diagnostic test and the risks associated with skin cancer are too great to treat empirically or observe. I agree with you that a punch biopsy is the most suitable course of action for Mr. Fitzgerald at this point in time. Of course, we’ll have to obtain his consent first.”
She picks up a sheet of paper and shows you the consent form (PDF).
You and Dr. Hill return to the room to speak with Mr. Fitzgerald. Dr. Hill says, “The skin lesion on your left forearm seems to be a patch of long duration. As you were exposed to the sun during your working years and even now through biking, there is a possibility that this lesion could be either a condition that leads to skin cancer or an early stage of skin cancer. We would like to take a small piece of tissue out of the lesion and take a look at it under a microscope. Then we can tell you exactly what the diagnosis is. We call this procedure a biopsy. There are different ways of doing biopsies, but the best way for your case is to use a cylindrical punch to take the tissue out under local anesthesia.”
Mr. Fitzgerald says, “What if I don’t want to do the procedure?”
“Well, if that is the case,” Dr. Hill answers, “we would not know the exact diagnosis and do not know how to treat your skin condition. And if it is truly a skin cancer, it could get worse and may proceed to an advanced stage, which is difficult to treat.”
“Well then I guess it is better for me to do it,” sighs Mr. Fitzgerald.
“I agree.” Dr. Hill tells him. “Here is the form for you to sign. The risk with this procedure is that obviously, you will have a scar after the procedure. There is also a small chance of bleeding and infection, even though we do our best to prevent these things. Do you have any questions?”
Mr. Fitzgerald does not have further questions and signs his name on the form. Dr. Hill also signs her name on the form and asks the medical assistant to sign their name as a witness. Then, Mr. Fitzgerald is escorted to the procedure room and the area of the skin lesion is cleansed with povidone solution.
You and Dr. Hill enter the procedure room. You watch as she disinfects the area with povidone solution and infiltrates the area of biopsy with 1% lidocaine solution using a 25 gauge needle.
After properly draping the area, she uses a 3 mm disposable punch and performs the punch biopsy at the periphery of the lesion. After taking out a small portion of the lesion and putting it in a formalin jar, Dr. Hill places a Steri-Strip to approximate the edge of the skin of the biopsy site.
She then applies compressive dressing and tells Mr. Fitzgerald to keep the wound dry for the next three days, and after that, to air dry the area. She mentions that the Steri-Strip may fall off after a few days. She instructs Mr. Fitzgerald that if he sees that the wound is getting inflamed about six to seven days after the procedure, or sees pus coming out at any time, he should contact Dr. Hill without delay. She finally discusses how to manage possible bleeding.
The specimen is sent to the pathology lab and Dr. Hill asks Mr. Fitzgerald to come back to the office in about seven to ten days for follow-up.
A week has passed, and you see that Mr. Fitzgerald is on the schedule for his follow-up appointment.
You look up Mr. Fitzgerald’s electronic medical record (EMR) and find:
Pathology report of the punch biopsy: Squamous-cell carcinoma in-situ (Bowen disease).
You do some research on the office computer to figure out what the treatment options are. You discover that one factor to consider when determining which treatment to prescribe is the risk of recurrence and metastasis.
After you have discussed treatment options with Dr. Hill and agree that wide excision is the best treatment for Mr. Fitzgerald, you and Dr. Hill go together to see him.
You find him seated in the exam room next to a young woman whom he introduces as his daughter Sarah, who is a nurse.
Dr. Hill begins, “We’ve received the results from your biopsy and you have what is called cutaneous squamous cell carcinoma in situ.”
“Just what we were afraid of, cancer,” sighs Sarah.
“I know that sounds scary, but these skin cancers are usually treatable. In fact, you have a particularly slow-growing form of squamous cell carcinoma called Bowen Disease. This has a very good prognosis. How are you feeling Mr. Fitzgerald?” Dr. Hill asks.
Mr. Fitzgerald says, “I thought that something was wrong and that was why I did not want to come to see you, but am I going to be okay?”
“Luckily, it is very likely treatable without any harm. There are a few treatment options for this. I recommend what we call a wide excision. This can be done in the office under local anesthesia. The spot is cut out and a margin of normal tissue around it. The sample is sent for histological testing to make sure that we’ve gotten all of the cancer. This procedure has a 95% cure rate.”
“Another method to take it out is Mohs micrographic surgery. We can confirm complete excision by immediately reviewing pathology, and then removing more tissue if necessary. I don’t think this is necessary in your case since we can see the edges of the spot on your forearm very clearly, so we should be able to get all of the cancer on the first attempt. Furthermore, this is on your arm, not near any important structures like your eyes or nose; so we can make sure to remove enough area to get the cancer, and we won’t need to worry about plastic surgery.”
“Are there options other than surgery?” Mr. Fitzgerald wants to know.
“Because this lesion could spread if untreated, surgical removal is the best approach. This allows us to confirm that the surgical margins are free of disease. But if you feel you really don’t want surgery, we can offer you alternative treatments that destroy cells such as topical 5-florouracil (5-FU), or cryotherapy.”
“Sounds like I’d better have the surgery done that you said you can do here,” Mr. Fitzgerald decides.
After obtaining the consent form, the excision of the lesion is done successfully by Dr. Hill and the specimen is sent to pathology. After the procedure, Dr. Hill gives Mr. Fitzgerald detailed postoperative wound care instructions and asks him to return for follow-up in ten days.
Dr. Hill asks you to provide Mr. Fitzgerald with some education about protection against further sun exposure and damage. You go online and print out a handout on skin cancer and prevention with information on protection against sun damage.
You discuss this with Mr. Fitzgerald and give him the handout.
Ten days later, Mr. Fitzgerald returns for follow-up. After examining his skin, Dr. Hill says, “There is no drainage from the wound and the margins are well-approximated. The wound is well-healed.” She then takes out stitches and continues, “Make sure that you wear a wide-brimmed hat when you go out in the sun and do not expose yourself to the sun unnecessarily. Do you have any questions?”
“Doctor, my daughter, Sarah, is very worried about me, and she’s asking me to get some information about what to look for on my skin.”
Dr. Hill advises Mr. Fitzgerald on what to look for.
Mr. Fitzgerald thanks you both for the information regarding the care of his skin. Then he says, “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?”
Dr. Hill asks you what would be your differential diagnoses in this case.
You say, “Considering the age and symptoms, BPH would be one of my top differential diagnoses, but I also think that we need to rule out acute or chronic prostatitis, and prostate cancer could be a very remote possibility.”
Dr. Hills says, “You are right in your differential diagnoses.”
Dr. Hill says to Mr. Fitzgerald, “It is quite likely that you have a condition called benign prostatic hyperplasia. Why don’t you make an appointment with me in a week or two so that we can look into this more to ensure we aren’t missing anything more worrisome? In the meantime, I’d like you to have a few tests done so we can have the information we need on hand the next time you come in. Also, please complete this questionnaire which will help us to better understand your condition.”
As Dr. Hill speaks with Mr. Fitzgerald, you think about how to assess Mr. Fitzgerald’s condition.
The next week, Mr. Fitzgerald returns to the office for evaluation of his prostate problem. You look up the laboratory results.
PSA: 1.6 ng/ml.
You also review the results of his AUA BPH Symptom Index questionnaire.
You and Dr. Hill visit Mr. Fitzgerald together. With his permission, Dr. Hill performs a digital rectal exam and tells you, “Mr. Fitzgerald’s prostate is slightly enlarged, but I could not appreciate any nodule from each lobe of the prostate. He does not have any prostate tenderness either.”
You and Dr. Hill step out of the room to allow Mr. Fitzgerald to change back into his clothes.
When you return, Dr. Hill begins, “Mr. Fitzgerald, as we suspected, you have what is called ‘benign prostatic hyperplasia’ or BPH. This refers to the increase in the size of the prostate that often occurs in middle-aged and older adult males. As you see in this picture, this enlargement of the prostate can compress the urethral canal to cause partial obstruction of the urethra, which interferes with the normal flow of urine; causing the urinary symptoms you have described.”
Mr. Fitzgerald wants to know,
“Does this mean I’m going to have prostate cancer?”
“No. BPH is not considered a precancerous condition. On your rectal exam, I found your prostate symmetrically firm and enlarged, which indicates BPH. If your prostate had felt harder or irregular on its surface or not symmetric I would be concerned that you could have prostate cancer. Your PSA is low enough that we don’t need to repeat it unless your symptoms get worse.”
You explain to Mr. Fitzgerald what he can do to improve his symptoms.
Mr. Fitzgerald indicates that he doesn’t have any other questions. He thanks you and Dr. Hill for your time and prepares to leave.
As he was leaving Mr. Fitzgerald says, “Oh, I almost forgot to mention this, but I have one unrelated question. I’ve been having some trouble with my feet lately. Can we address that now as well?”
“Sure!” Dr. Hill smiles and agrees to hear about Mr. Fitzgerald’s concern, although you know she has patients waiting to be seen.
“It is a relatively minor matter,” he claims, “but I have been noticing this burning sensation for the last week after I stepped in a mud puddle as I changed my bike route. I rode the bike continually in a damp right shoe and sock as I did not bring spare socks with me. Do you want to take a look at them?”
Dr. Hill nods and proceeds to examine Mr. Fitzgerald’s feet. After removing his shoes and socks, the patient points to his toes, drawing your attention to the redness present in the interdigital spaces. “Do you have any fever, swelling, or other problems associated with this?” you inquire.
“No, just the burning and this redness,” the patient says.
You inspect Mr. Fitzgerald’s feet. You check between each toe looking for broken skin and find dry, red skin with occasional cracks in each web space. There is also redness proximal to the toes on the dorsum of the foot with the same dry appearance. You feel no warmth and Mr. Fitzgerald reports no pain to palpation. There is no swelling and noting equal pulses in each of the feet.
Dr. Hill asks you,
“What condition may be causing Mr. Fitzgerald’s dry, cracking, erythematous skin between toes?”
You respond that you think Mr. Fitzgerald has tinea pedis. Dr. Hill congratulates you on your diagnostic accuracy. She explains to you and Mr. Fitzgerald that he has “a classic case of tinea pedis-or in lay terms ‘athlete’s foot.”