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To prepare:

· Review the Skin Conditions document provided in this week’s Learning Resources, and select two conditions to closely examine for this Discussion.

· Consider the abnormal physical characteristics you observe in the graphics 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.

By Day 3

Post a description of the two graphics you selected (identify each graphic by number). Use clinical terminologies to explain the physical characteristics featured in each graphic. Formulate a differential diagnosis of three to five possible conditions for each. Determine which is most likely to be the correct diagnosis, and explain your reasoning.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days Make sure that you respond to colleagues who selected at least one graphic that is different from the ones you selected. For each, address all of the following:

· Critique your colleague’s clinical description of the physical characteristics of each.

· Suggest an additional possible condition for each graphic, and explain your reasoning.

· Provide an alternative correct diagnosis, and explain your reasoning.

· Validate an idea with your own experience and additional research.

Comprehensive SOAP

SLIDE 2:

Patient Initials: __MP_____ Age: ___68____ Gender: _M

SUBJECTIVE DATA:

Chief Complaint (CC): Annual physical and multiple hard red bumps on my chest

History of Present Illness (HPI): Mike Palmer is a 68-year-old Caucasian male who presents today for annual physical and want to address multiple hard red bumps on his chest appearing. He reports there is a gradual onset of at least 4 new areas on his chest then last year. He is concerned he may have tumors because he did a google search and reported it said he had tumors on his chest. He denies any itching, pain, exudate, bleeding, color changes or climate variations. He reported they are located on his abdomen and chest. He denies any fever, new medications and no exposure to contact irritants. No increase in stress or lifestyle changes. No personal or family history of skin cancer.

Medications:

1. Metoprolol 50mg BID

Allergies:

NKDA

Past Medical History (PMH):

1. Hypertension: diagnosed at age 54 – well controlled

Past Surgical History (PSH):

1. Repair of a torn rotator cuff, left shoulder (Dr. Bakker, Grand Haven, MI), age 40

Sexual/Reproductive History:

Heterosexual, not sexually active

Personal/Social History:

Never smoked, denied ETOH or illicit drug use.

Immunization History:

His immunizations are up to date. He received the influenza vaccine last November 2016 and the Pneumococcal vaccine at the same time from Walgreens Pharmacy

Significant Family History:

Both parents deceased from car accident, no siblings. He has one daughter in her 30s, healthy, living in nearby neighborhood.

Social History:

He is a retired engineer, has been widowed x 7 years, and lives in his own home. He is not sexually active. He has one daughter and three grandchildren, all live close to him. He is very active and walks 2 miles daily. He attends Catholic mass daily then goes to breakfast at the same diner every morning with a group on 7 friends at the local diner.

Review of Systems:

General: Mr. Palmer is a well-developed, well-nourished Caucasian male who is alert and cooperative. Good hygiene. He is a good historian and answers questions appropriately.

HEENT: No changes in vision or hearing; he does wear glasses, and his last eye exam was 6 months ago. He reported no history of glaucoma, diplopia, floaters, excessive tearing, or photophobia. He has had no recent ear infections, tinnitus, or discharge from the ears. He reported her sense of smell is intact. He has not had any episodes of epistaxis. He does not have a history of nasal polyps or recent sinus infection. Nares patent bilaterally. Nasal mucosa pink without rhinorrhea. No sinus tenderness. Oropharynx without erythema or exudate. Buccal mucosa intact. His last dental exam was 01/2017. He denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. He has had no difficulty chewing or swallowing.

Neck: Supple, full range of motion. No thyromegaly. No carotid bruits. No masses palpated. No tracheal deviation noted.

Breasts: No history of lesions, masses, or rashes.

Respiratory: Breath sounds clear all fields. Diaphragmatic excursion is symmetrical

CV: No chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication.

GI: No nausea or vomiting, reflux controlled. No abd pain, no changes in bowel/bladder pattern.

GU: No change in his urinary pattern, dysuria, or incontinence. He is heterosexual. He has not been sexually active since the death of his spouse.

MS: He has no arthralgia/myalgia, no arthritis, gout or limitation in his range of motion by report. History of rotator cuff repair due to injury

Psych: No history of anxiety or depression. No sleep disturbance, delusions, or mental health history. He denied suicidal/homicidal history.

Neuro: No syncopal episodes or dizziness, no paresthesia, headaches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history.

Integument/Heme/Lymph: 32 1-3 mm hard, raised papule bright red in color, scattered over the chest and abdomen, they do not blanch with pressure.

Endocrine: No endocrine symptoms or hormone therapies.

Allergic/Immunologic: Has hx of allergic rhinitis

OBJECTIVE DATA

Physical Exam:

Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 orally; RR 16; non-labored; Wt: 185 lbs; Ht: 6’2; BMI 21

General: A&O x3, NAD, appears mildly uncomfortable

HEENT: PERRLA, EOMI, oronasopharynx is clear

Neck: Carotids no bruit, jvd or tmegally

Chest/Lungs: CTA AP&L

Heart/Peripheral Vascular: RRR without murmur, rub, or gallop; pulses+2 bilat pedal and +2 radial

ABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound

Genital/Rectal: Deferred

Musculoskeletal: symmetric muscle development - some age-related atrophy; muscle strengths 5/5 all groups

Neuro: CN II – XII grossly intact, DTR’s intact

Skin/Lymph Nodes: 32 1-3 mm hard, raised papule bright red in color, scattered over the chest and abdomen, they do not blanch with pressure.

ASSESSMENT:

Lab Tests and Results:

SAO2 – 98%

Diagnostics:

DEFERRED

Differential Diagnosis (DDx):

1.) Cherry angioma- Cutaneous vascular proliferation which manifests as single or multiple spots and occurs predominantly on the upper trunk and arms. They typically appear as round-to-oval, bright, red, dome-shaped papules and pinpoint macules measuring up to several millimeters in diameter. The histopathologic findings of a cherry angioma are consistent with a true capillary hemangioma, which is formed by numerous, newly developed capillaries with narrow lumens and prominent endothelial cells arranged in a lobular fashion in the papillary dermis. The etiology of cherry angiomas is not well-known. However, since cherry angiomas tend to increase in number as the patient's age increases, 75% of adults over 75 years of age were observed in a recent study, the aging process may play a role in the pathogenesis of cherry angiomas (Kim, Park, and Ahn, 2009).

2.) Glomeruloid hemangioma-Small, firm, red-to-violaceous, dome-shaped papules, papulonodules, subcutaneous bluish compressible tumors, wine-red sessile or pedunculated papules, or lesions with cerebriform morphology. They range in size, measuring few millimeters to few centimeters in diameter, and are located mainly on the trunk and proximal limbs and is characterized by a solitary or multiple blue-red papules (Gupta, Kandhari, Ramesh, and Singh, 2013).

3.) Angiokeratoma corporis diffusum- Characterized histologically by superficial ectatic vessels with epidermal proliferation. Red to purple, hyperkeratotic and coalescing papules, occurs most typically on the lower region of the trunk, buttocks, and thighs and is usually associated with Lyosomal storage diseases (Jayavardhana, Balasubramanian, and Vijayalakshmi, 2015).

Diagnoses/Client Problems of Image #2:

1.) Cherry angioma-Cherry angioma are found in the lower papillary dermis and occur in virtually everyone older than 30 years and increase numerically with age (Ball, Dains, Flynn, Solomon, and Stewart, 2015). Glomeruloid hemangioma is vascular proliferation and appears suddenly on the trunk, extremities, head, and neck region therefore it is ruled out (Gupta, Kandhari, Ramesh, and Singh, 2013). Lyosomal storage diseases were not present as all enzyme lab work was normal in the patient therefore Angiokeratoma corporis diffusum was ruled out.

PLAN: Discussed normal findings with patient. If treatment is desired for cosmetic appearance, irritation or bleeding; may refer to dermatology for electrocautery or laser therapy (Kim, 2009). Patient declines at this time but may consider at a later date.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Gupta, J., Kandhari, R., Ramesh, V., & Singh, A. (2013). Glomeruloid hemangioma in normal individuals. Indian Journal Of Dermatology, 58(2), 160. doi:10.4103/0019-5154.108088

Jayavardhana, A., Balasubramanian, P., & Vijayalakshmi, A. M. (2015). Angiokeratoma corporis diffusum. Indian Pediatrics, 52(2), 175. Retrieved from Walden Library database

Kim, J., Park, H., & Ahn, S. K. (2009). Cherry Angiomas on the Scalp. Case Reports In Dermatology, 1(1), 82-86. Retrieved from Walden Library database

Comprehensive SOAP

SLIDE #5

Patient Initials: __MP_____ Age: ___68____ Gender: _M

SUBJECTIVE DATA:

Chief Complaint (CC): Annual physical and my psoriasis

History of Present Illness (HPI): Mike Palmer is a 68-year-old Caucasian male who presents today for psoriasis. Onset was 51 years; diagnosed with psoriasis when he was in high school by his PCP. New areas of plaques identified continuous spread to other parts of his skin. He denies any pain. He denies any fever, new medications and no exposure to contact irritants. No increase in stress or lifestyle changes. No personal or family history of skin cancer.

Medications:

1. OTC Mens Health Multivitamin

Allergies:

NKDA

Past Medical History (PMH):

1. Psoriasis

Past Surgical History (PSH):

1. Repair of a torn rotator cuff, left shoulder (Dr. Bakker, Grand Haven, MI), age 40

Sexual/Reproductive History:

Heterosexual, not sexually active

Personal/Social History:

Never smoked, denied ETOH or illicit drug use.

Immunization History:

His immunizations are up to date. He received the influenza vaccine last November 2016 and the Pneumococcal vaccine at the same time from Walgreens Pharmacy

Significant Family History:

Both parents deceased from car accident, no siblings. He has one daughter in her 30s, healthy, living in nearby neighborhood. Aunt positive for psoriasis

Social History:

Review of Systems:

General: Mr. Palmer is a well-developed, well-nourished Caucasian male who is alert and cooperative. Good hygiene. He is a good historian and answers questions appropriately.

Neck: Plaque involvement diffusely on his central face with erythema and scaling. Diffuse involvement of his scalp and preauricular cheek.

Breasts: No history of lesions, masses, or rashes.

Respiratory: Breath sounds clear all fields. Diaphragmatic excursion is symmetrical

CV: No chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication.

GI: No nausea or vomiting, reflux controlled. No abd pain, no changes in bowel/bladder pattern.

GU: No change in his urinary pattern, dysuria, or incontinence. He is heterosexual. He has not been sexually active since the death of his spouse.

MS: He has no arthralgia/myalgia, no arthritis, gout or limitation in his range of motion by report. History of rotator cuff repair due to injury.

Psych: No history of anxiety or depression. No sleep disturbance, delusions, or mental health history. He denied suicidal/homicidal history.

Integument/Heme/Lymph: Plaque involvement diffusely on his central face with erythema and scaling. Diffuse involvement of his scalp and preauricular cheek

Endocrine: No endocrine symptoms or hormone therapies.

Allergic/Immunologic: Has hx of allergic rhinitis

OBJECTIVE DATA

Physical Exam:

Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 orally; RR 16; non-labored; Wt: 185 lbs; Ht: 6’2; BMI 21

General: A&O x3, NAD, appears mildly uncomfortable

HEENT: Plaque involvement diffusely on his central face with erythema and scaling. Diffuse involvement of his scalp and preauricular cheek.

Neck: Carotids no bruit, jvd or tmegally

Chest/Lungs: CTA AP&L

Heart/Peripheral Vascular: RRR without murmur, rub, or gallop; pulses+2 bilat pedal and +2 radial

ABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound

Genital/Rectal: deferred

Musculoskeletal: symmetric muscle development - some age-related atrophy; muscle strengths 5/5 all groups

Neuro: CN II – XII grossly intact, DTR’s intact

Skin/Lymph Nodes: well demarcated, raised, erythematous plaques with a white scaly surface located primarily on the extensor surfaces of the body, involving 80% of body surface area. No bleeding present. Nail changes with pitting, onycholysis, discolouration and dystrophy with crumbling of the nail plate.

ASSESSMENT:

Lab Tests and Results:

SAO2 – 98%

Diagnostics:

DEFERRED

Differential Diagnosis (DDx):

1. Psoriasis-Chronic inflammatory skin disease, with a strong genetic basis, characterized by complex alterations in epidermal growth and differentiation and multiple biochemical, immunologic, and vascular abnormalities (Ball, Dains, Flynn, Solomon, and Stewart, 2015).

2. Eczema-An immune system disorder characterized by over-reaction of an allergic nature. Typically starts in infancy or childhood, with the symptoms becoming less severe as the child grows older and tend to appear in the crooks of the knees and elbows (Watkins, 2016).

3. Seborrheic Dermatitis-Characteristic symptoms-scaling, erythema, and itching-occur most often on the scalp, face, chest, back, axilla, and groin. Seborrheic dermatitis is a clinical diagnosis based on the location and appearance of the lesions. The skin changes are thought to result from an inflammatory response to a common skin organism (Clark, Pope, and Jaboori, 2015).

Diagnoses/Client Problems:

1.) Psoriasis was chosen as it presents with symmetric, well demarcated, erythematous plaques with overlying silvery scales, and accompanied with mild pruritus. Nail changes were noted with pitting, onycholysis, discolouration and dystrophy with crumbling of the nail plate. (Ball, Dains, Flynn, Solomon, and Stewart, 2015). Eczema appears to have a papulovesicular peripheral border distinguishing it from psoriasis. Also the onset of eczema is typically in infancy and childhood and improve with age, therefore eczema was ruled out (Watkins, 2016). Seborrheic dermatitis has lesions that are erythematous with a yellowish hue and are covered with large greasy scales that can be detached easily therefore it is ruled out (Clark, Pope, and Jaboori, 2015).

PLAN: Clobetasol Ointment 0.05% applied to plaques BID x 14 days. Follow up appointment in 1 month

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Clark, G. W., Pope, S. M., & Jaboori, K. A. (2015). Diagnosis and treatment of seborrheic dermatitis. American Family Physician, 91(3), 185-190. Retrieved from Walden Library databases

Watkins, J. (2016). Management of eczema and psoriasis in the community. British Journal Of Community Nursing, 21(6), 274-279. Retrieved from Walden Library databases