Differential Diagnosis for Skin Conditions Paper

In this Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition. To prepare: Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Assignment. Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies? Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected. Consider which of the conditions is most likely to be the correct diagnosis, and why. Download the SOAP Template found in this week’s Learning Resources. To complete: Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format, rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week\’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case. Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. Differential Diagnosis for Skin Conditions Paper. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least 3 different references from current evidence based literature.

Subjective Data
Slide #2

Patient’s Initials-JK
Age-70
Gender-M
Chief Complaint
Multiple physical hard bumps on my chest which are red in color
History of Present Illness
JK is a 70-year-old Asian American male who presented today for an annual physical exam with the concern of addressing multiple hard red bumps on the chest that had been in existence for a year now. He reported that the bumps were of gradual onset on different parts of the chest and were 4 in number. The patient declined pain, itching, bleeding, exudates, and color changes. The swellings were located on the chest and the abdomen. The client reported no recent use of new medications, exposure to irritants and fever but was concerned that it could have been cancer. The client further denied recent stress and lifestyle changes and a family history of cancer.
Medications
Losartan H 50mg BD
Allergies
NKDFA
Past Medical History
He is a well-known hypertensive patient that was diagnosed at 50 years of age. It is however well controlled.
Past Surgical History
Underwent an appendectomy at 40 years of age
Sexual and Reproductive Health History
The patient is heterosexual and not sexually active
Personal Socio-economic History
Denied ETOH, use of illicit drugs and tobacco smoking
Immunization History
All immunizations are up to date. Pneumococcal and Influenza vaccine was received in November 2017.
Family History
All parents are deceased. The father died following a tragic road traffic accident while the mother died from renal failure as a result of type 2 diabetes mellitus complication. Has one sibling who is well and alive. Has one son in his 30s, alive and well who lives in a neighborhood nearby. Differential Diagnosis for Skin Conditions Paper.

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Social History
The client is a retired banker, has been widowed for 6 years and lives in his own home and is not sexually active. He has one son and two grandchildren who live nearby. He is physically active as he walks up to 3 miles daily. Is a Christian of the Catholic denomination and attends church routinely every morning at a local diner.
Review of Systems
General: JK is in a fair general condition, well-nourished, alert and co-operative. He has good hygiene and answers questions accurately and appropriately.
HEENT: No changes in hearing and vision; he wears glasses and had an eye exam done 7 months ago. The client reported no history of excessive tearing, photophobia, diplopia or floaters. He also reported no recent infections of the ear, discharge or tinnitus. The sense of smell was reportedly intact with no episodes of epistaxis, no recent infection of the sinus or nasal polyps. Bilaterally, both nares were patent; the nasal mucosa was pink in color with no rhinorrhea or nasal tenderness. The oropharynx had no exudate or erythema and the buccal mucosa was intact. He last had a dental exam 12 months ago. He declined any ulcerations, bleeding in the gums, gingivitis, and lesions. He also reported no difficulties I swallowing and chewing.
Neck: the client’s neck was supple, with a full range of motion. No enlargement of the thyroid, carotid bruits, no deviation of the trachea or palpated masses.
Breasts: No history of masses, rashes or lesions.
Respiratory: No Difficulty in Breathing, Chest pain or discomfort. Had a symmetrical diaphragmatic excursion
CV: No palpitations, history of arrhythmias, murmurs, orthopnea, claudication or paroxysmal nocturnal dyspnea.
GI: No vomiting or nausea but had controlled reflux. No abdominal pains or changes in the bladder.
GU: Reported no changes in bladder patterns, no hematuria, dysuria or urinary incontinence. As a heterosexual, he hasn’t been sexually active since the death of his wife.
MS: no myalgia, arthritis, arthralgia, gout or movement limitation.
Psych: Bo history of anxiety or depression, delusions or any mental health illnesses. The client also denied homicidal and suicidal ideation.
CNS: The client reported no incidences of dizziness, episodes, headaches or paresthesia. There were reportedly no changes in thinking and memory patterns, abnormal body movements, disturbance in gait or coordination of body movements. The client also reported no history of seizures or falls.
IS: The client had hard raised papule bright red in color that was scattered all over the abdomen and chest. The papules were approximately 1-3 mm in size and 30 in number. With pressure, the papules didn’t blanch.
Endocrine: no hormonal therapies or endocrine symptoms.
Allergic/Immunologic: the client has a history of allergic rhinitis.
Objective Data
Physical Examination
Vital Signs: B/P 110/70mmhg, Pulse 70 regular, Temp 98.4 orally, RR 16 non-labored, Weight186lbs, Ht6’2, BMI 21.
Physical Exam:
General: alert and oriented X3 and appeared to be mildly uncomfortable.
HEENT: PERRLA, EOMI with a clear oronasopharynx
Neck: no bruit on the carotid, JVD or tmegally.
RS: Lungs/Chest: AP, CTA & L
CVS: pulses+2 bilateral pedal and +2 radial, had a RRR without a gallop, rub or murmur.
Abdomen: no organomegaly, mild diffuse tenderness on the suprapubic region that was not rebound, benign nabs x5
Genital: Deferred
Musculoskeletal: muscles developed symmetrically with some atrophy that can be associated with age. In all groups, muscle strength was 5/5. Differential Diagnosis for Skin Conditions Paper.
Neuro: CN II-XII intact, DTR was also intact.
Skin: 30 1-3 mm hard, bright red raised papule over the abdomen and chest which do not blanch even with pressure.
Assessment
Laboratory tests and results: SAO2-99%
Diagnostics- Deferred
Differential Diagnosis (DDx):
a. Cherry angioma- this refers to a vascular proliferation that either manifests as a single or multiple spots cutaneously on the arms and upper trunk. They often appear oval, round or dome-shaped and bright red in color papules or macules that are pinpointed that measure up to several millimeters in diameter. Based on histopathology, the findings the cherry angioma is similar to a true capillary hemangioma (Borghi et al., 2016). The latter forms through numerous capillaries that are newly developed with a narrowed lumen and prominent endothelial cells organized in a lobular manner in the papillary dermis. A cherry-angioma has no well-known etiology. Though, they tend to increase with the patient’s increase in age (Borghi et al., 2016). This, therefore, means that the natural aging process plays a significant role in a cherry angioma pathogenesis.
b. Glomeruloid Hemangioma- are usually firm, small, dome-shaped papulonodules or papules that are red, bluish or violet compressible tumors. They tend to have different sizes and are mainly found on the trunk and proximal limbs and are characterized by multiple or solitary blues and red papules (Shinozaki-Ushiku et al., 2018).
c. Angiokeratoma corporis diffusum- based on histopathology, it is characterized by superficial ectatic vessels with proliferation on the epidermis. They might be red or purple in color, hyperkeratotic and coalescing papules. They commonly occur on the lower trunk region, on the thighs and buttocks and are often associated with diseases of lysosomal storage (Prasad & Joshi, 2016).
Specific Diagnosis in Image #2
Cherry Angioma-cherry angiomas are usually located in the lower papillary dermis and can occur in anyone above 30 years and continue to increase with age. Glomeruloid hemangiomas are vascular proliferation with a sudden onset on the extremities, the head, neck, and trunk thus ruled out in this case (Habif et al., 2017). Angiokeratoma corporis diffusum exists in patients with lysosomal storage illnesses which in this case, were not present since lab tests were normal thru ruling out its possibility.
Plan
The normal findings were discussed with the patient. In case the patient desired treatment for cosmetic purposes, irritation, bleeding or to enhance his appearance, possible referral to a dermatologist for laser therapy or electrocautery will be considered (Robati & Ghasemi‐Pour, 2018). At this time the patient may decline but may reconsider at a later date. Differential Diagnosis for Skin Conditions Paper.

References
Borghi, A., Minghetti, S., Battaglia, Y., & Corazza, M. (2016). Predisposing factors for eruptive cherry angiomas: New insights from an observational study. International journal of dermatology, 55(11), e598-e600.
Habif, T. P., Chapman, M. S., Dinulos, J. G., & Zug, K. A. (2017). Skin Disease E-Book: Diagnosis and Treatment. Elsevier Health Sciences.
Prasad, R., & Joshi, S. (2016). Angiokeratoma corporis diffusum (Fabry disease)-A case report. The Journal of the Association of Physicians of India, 64(1), 73-73.
Robati, R. M., & Ghasemi‐Pour, M. (2018). Efficacy and safety of cryotherapy vs. electrosurgery in the treatment of cherry angioma. Journal of the European Academy of Dermatology and Venereology.
Shinozaki-Ushiku, A., Higashihara, T., Ikemura, M., Sato, J., Nangaku, M., Ushiku, T., & Fukayama, M. (2018). Glomeruloid hemangioma associated with TAFRO syndrome. Human Pathology.

Comprehensive SOAP Template

This template is for a full history and physical. For this course include only areas that are related to the case.

Patient Initials: __    _____             Age: _______                                   Gender: _______

Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.

L =location

O= onset

C= character

A= associated signs and symptoms

T= timing

E= exacerbating/relieving factors

S= severity

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.

History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale 

Medications: Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency. Differential Diagnosis for Skin Conditions Paper. 

Allergies: Include specific reactions to medications, foods, insects, and environmental factors. Identify if it is an allergy or intolerance.

Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations.

Past Surgical History (PSH): Include dates, indications, and types of operations.

Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and risky sexual behaviors.

Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.

Immunization History: Include last Tdap, Flu, pneumonia, etc.

Significant Family History: Include history of parents, grandparents, siblings, and children.

Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference.

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Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you so ensure that you include all essentials in your case (refer to Chapter 2 of the Sullivan text). Differential Diagnosis for Skin Conditions Paper.

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

            HEENT:

Neck:

            Breasts:

            Respiratory:

            Cardiovascular/Peripheral Vascular:

            Gastrointestinal:

            Genitourinary:

            Musculoskeletal:

            Psychiatric:

            Neurological:

            Skin: 

Hematologic:

            Endocrine:

            Allergic/Immunologic:

OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P- only in this course. Do not use “WNL” or “normal.” You must describe what you see.

Physical Exam:

Vital signs: Include vital signs, ht, wt, and BMI.

General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of consciousness, and affect and reactions to people and things. Differential Diagnosis for Skin Conditions Paper.

HEENT:

Neck:

Chest

Lungs:

Heart

Peripheral Vascular: Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. 

ASSESSMENT: List your priority diagnosis (es). For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan. 

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. 

REFLECTION: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. Reflect on your clinical experience, and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence? Differential Diagnosis for Skin Conditions Paper.