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Amy Triptyline is a 59 year old retired lady who has presented to dermatology clinic for review of a lesion.

Please take a history from Amy and perform the appropriate examination. You will then be asked to discuss the case with the examiner.

You are Amy Triptyline, a former dinner lady who has been retired for a few years now. You won the lottery on your 45th birthday, and since then you have lived abroad. Unfortunately, you feel that you are now paying back for that good luck!

HPC: You never noticed any lumps or bumps on your skin – it was Paolo, the pool boy who actually noticed the lesion that has brought you into hospital. He always did take notice of you than your ex-husband did. Your husband always saw you, but he never really saw you. Anyway.

The lesion started off as a bit of a big mole. It was a bit of a funny shape, and grew slowly and gradually. It was funny at the time: the more you looked at it, the more you convinced yourself it actually looked like a mole – as in the small woodland mammal. The mole didn’t just get bigger, it seemed to change colour as well. It went from being a pale brown colour – like a nice mahogany table – to the colour of coal. You thought at the time that this was just down to your recent tan.

The mole did bleed from time to time – but it was at the point of your bra strap and you feel that you were occasionally nicking it by accident. It occasionally was itchy and flakey too.

You have had lots of moles in the past – seems like you’ve got hundreds of them! However, they’ve never given you any bother in the past, so you’re not sure why this one would be any different at all. You haven’t got any rashes anywhere else on your body. You haven’t noticed any weight loss, unfortunately – you would love to lose a bit of weight. You’ve never had the patience, and find those weight loss programmes ghastly.

PMH: You have always been relatively well. You had a bad case of flu last summer – you’re convinced it was swine flu. It brought you into hospital and you had to go into an isolation room. However, that meant that you got your own private room, which was perfect: no sharing with the dreadful local sick people! You’re not allergic to anything, and you don’t take many regular tablets. You take cod liver oil and vitamin C tablets, and they keep you just right!

ICE: You began to become worried about this mole when it started to get so noticeable that your ex-husband picked up on it. It must have been huge if he saw it! That was a couple of months ago – you then decided that you would fly back to the UK to get it seen to. You don’t trust the local doctors in Gran Canaria.

You were hoping that it would just be a simple mole and nothing too bothersome – you are very moley after all! Unfortunately, the doctors told you that they thought it was a type of skin cancer. That has scared you, and you have stuck around in your UK home since then. You feel so bad about all the sunbathing you have done in the last few years… but what else were you supposed to do with all that lottery money! You earned that time to yourself, to do whatever you liked!

SH: You live in a lovely villa in Gran Canaria. You don’t do any work any more – you spend most of your time sunbathing outside on the lawn, or sometimes by the pool. You grew up in the UK and occasionally used sunbeds – you’ve always hated how pale you were. You like to feel very tan, because then all your freckles and moles don’t stand out as much. You were married to your husband, Nigel, however you feel that he has been living off your winnings for far too long, and has become so ungrateful. Since you got the news about the cancer, you told him to pack his bags and leave – life is far too short for people like that! You’re not very active, but do occasionally go swimming.

FH: Your mum died of bowel cancer when you were very young, and your dad left when you were young so you didn’t know him.

The student should take a focused history of this lesion, focusing on risk factors for malignant melanoma of the skin. A skin examination would be appropriate.

A good example of a differential diagnosis would sound something like:

“My differential diagnosis would primarily be a dermatological cause: specifically malignant melanoma of the skin. This is because of the change in size, shape and colour of this lesion, with associated bleeding and itching, on a background of excessive sun exposure. This patient also likely has atypical mole syndrome, given her history of multiple moles. An alternative differential diagnosis would be benign naevus or blue naevus.”

Examples of questions for discussion would include: - How would you investigate this patient on first presentation? - What types of malignant melanoma are you aware of? - What risk factors are you aware of with regards to malignant melanoma? - How do we assess prognosis in malignant melanoma? - How is malignant melanoma managed?