Pre-module Survey:
https://ubc.ca1.qualtrics.com/jfe/form/SV_0TenPCZiTvEinVc
Relevant Specialties: family medicine, radiation oncology, pathology, dermatology.
Case
You are a first-year family medicine resident doing your rural family medicine in Provost, Alberta. Your first patient of the day is Mr. Smith, an 89-year-old man who presented with “a bug bite on the nose that keeps bleeding”. Before seeing the patient, you open his patient profile on the EMR which shows:
- ID:
- 89-year-old retired man
- CC:
- “A bug bite on the nose that keeps bleeding”
- Medical history:
- Myocardial infarction 10 years ago
- Congestive heart failure (left ventricular ejection fraction of 40%)
- Renal transplant 25 years ago for polycystic kidney disease
- Advanced bilateral glaucoma.
- Onychomycosis of toenails.
- Current medications:
- Ramipril 5 mg PO daily.
- Amlodipine 5 mg PO daily.
- Bisoprolol 10 mg PO daily.
- Rosuvastatin 5 mg PO daily.
- Mycophenolate 1g PO BID.
- Tacrolimus 1 mg PO BID.
- Prednisone 5 mg PO daily.
- Timolol and latanoprost eyedrops 1 drop to each eye at bedtime.
- Brinzolamide and brimonidine eyedrops 1 drop to each eye at bedtime.
- Allergies:
- NKDA
- Surgical history:
- Triple bypass surgery 10 years ago
- Family history:
- No family history of significant skin conditions or skin cancer
- Social history:
- Smoker with one pack a day (40 pack year history total), drinks 1-2 bottles of hard liquor on a weekly basis since her wife passed away 2 years ago, and denies recreational drug use.
- Worked as an outdoor construction worker his whole life, now retired and lives in an assisted living facility.
You introduce yourself to Mr. Smith and started the interview with some open-ended questions. You say, “Mr. Smith, I understand you have a bug bite on your nose that has been bothering you. Could you tell me what has been going on from the beginning?” He says that he noticed a small bump on his nose about 3 months ago. He thought it was just a bug bite and did not pay any attention to it. However, since then, the bump has been increasing in size and bleeding intermittently. He is frustrated because the bump does not seem to heal. It was ulcerated a bit one month ago, and it is very tender to touch. Upon further history, he mentions when he had a severe thermal burn to his nose about 5 years ago around the same location.
You ask Mr. Smith if he has any other concerning lesions on the rest of his skin. He shakes his head. He mentions he had bad fungal infection of his toenails about 10 years ago and was effectively treated with a 12-month course of oral voriconazole. Otherwise, no personal history of skin cancer.
After the interview, you decide to do a complete skin examination and Mr. Smith agrees. On examination, Mr. Smith is Fitzpatrick skin Type II. You do not find any suspicion lesion except the one on his nose:
