health assessment

Walden University

NURS-6512N-17

Advanced Health Assessment.

December 22, 2019.

Introduction

The number 2 graphic (figure below) is characterized as Cherry angiomas that appear in older adults. With time cherry angiomas turn dark, though after infection it is identified by round tiny bright ruby red papules. As age numerically increase Dunphy et al (2015) argues that the disease virtually occurs to everyone above the age of 30 years. One of the ways in which I would perform differential diagnosis is by observing the skin of a patient who is 70 years of age.

Graphic #2

Patient Initials: AB                             Age: 70                                 Gender: male 

SUBJECTIVE DATA:

Chief Complaint (CC): AB comes in clinic complaining about development of hard red bumps on the chest

History of Present Illness (HPI): Patient AB who is 70 years old comes in the hospital with complaints of having red bumps on his chest that appeared 2 weeks ago. He states that he wants to be done aa physical examination to be performed. AB says that last year he developed at least 4 new bumps on his chest that formed gradually. He is filled with anxiety because upon doing a Google search about his condition, he found that it could some tumors that are developing on his chest. He deniesrefutes any bleeding, painful and itchy bumps, exudation, or any climate variations. The bumps are located around the chest and the abdomen. AB says he has not come into contact with an irritant, denies having a fever, or does he take medications. Also, he reports he is neither under stress nor lifestyle changes. He claims, no one in his family lineage has ever been diagnosed with skin cancer. 

Medications:  none 

Allergies: NKDA

Past Medical History (PMH):  identified with stage 4 blood pressure Hypertension and the age of 60 which was well managed. 

Past Surgical History (PSH): At age 40, his left shoulder was repaired from a torn rotator cuff. 

Sexual/Reproductive History: Married and not sexually active. 

Personal/Social History: denies smoking, taking alcohol, substance abuse, or under any influence of ETOH 

Immunization History: His immunizations are current. In 2017, he got immunized of Pneumococcal vaccines and influenza vaccine

Significant Family History: Living with no parents who perished from a car accident. Living with his healthy daughter whom he got at his 30s

Social History:  Live with her daughter and his 3 grandchildren. Being a widow for 8 years, he has been working as an engineer before he retired. In his free time, he does light exercises. Every day he attends catholic mass and then joins his 6 friends for breakfast at the local diner. 

Review of Systems (ROS): 

General: Mr. AB is a well-organized and neat man. He is alert and corporate during the discussion. He responds to the question correctly and in-depth as he is a historian.  Comment by Kristin Curcio: These are objective findings. ROS is for subjective information – what the patient tells you.

HEENT: 

Eyes: clear vision and wears no glasses, and his last eye check-up was done six months ago. He refutes having any photophobia, excessive tearing, floaters, diplopia, and glaucoma. 

Ears: his ears are fine because he reports noDenies recent ear infection, discharge or tinnitus. 

Nose: intact smell. No history of polyps, epistaxis or recent sinus infection. Nasal mucosa with rhinorrhea.  Comment by Kristin Curcio: Exam finding.

Mouth: chews and swallows food with no difficulty. AB has healthy dental hygiene and did his last check-in in 2018.

Neck: No carotid bruits. No tracheal deviation noted. No masses palpated. No thyromegaly. Supple, full range of motion. Comment by Kristin Curcio: Exam findings.

Breasts: Refutes Denies any form of rashes, masses or lesions. 

Respiratory: No breathing difficulty. Symmetrical diaphragm excursion Comment by Kristin Curcio: Exam finding.

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

GI: has controlled reflux, no vomiting or nausea. The bladder/bowel pattern has not changed. No abdominal pain. 

GU: His urinary pattern, incontinence, and dysuria have not changed. Since he lost his spouse in his heterosexual relationship, he has been sexually inactive. 

MS: The report shows he does not have arthritis, gout or limitation of limb movement. History of rotator cuff repair due to injury. 

Neuro: No falls or seizure history. His range of motions and coordination are not limited. No history of abnormal muscle twitch; plus memory or thinking patterns, has not changed.

Integument /Lymph:  32 1-3 mm hard, raised papule bright red in color, scattered over the chest and abdomen, they do not blanch with pressure. Comment by Kristin Curcio: This would be your exam.

Endocrine: no history of hormonal therapies or endocrine symptoms

Allergic/Immunologic: the report indicate a history of allergic arthritis

OBJECTIVE DATA:

Physical Exam:

Vital signs: Temperature 95.4, orally; BP 133/78, pulse 68, R 19 and regular. He weighs176 pounds and is 5’7” with a BMI of 23.6

General: looks organized and well-groomed. 

HEENT: 

Neck: supple, full ROM. No JVD or bruit

Chest/Lungs: Breath sounds clear and regular bilaterally 

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

ABD: Soft, nontender. No distension, masses, or organomegaly; benign, nabs x 4, no organomegaly

Genital/Rectal: Postponed 

Musculoskeletal: fully weight-bearing. Full ROM in all extremities 

Neuro: A&O x3, cooperative. CN II-XII is intact. DTRs 2+ and symmetrical bilaterally

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:

1.)   Cherry angioma- Cutaneous vascular proliferation which predominantly occurs on the upper trunk and arms is manifested with single or multiple spots. Measuring up to several centimeters in diameter, they appear as a red, dome-shed, round-to-oval, bright red papules and pinpoint macules. Cherry angioma forms in the papillary dermis whereby histopathologic findings show that they appear as true capillary hemangioma with tapered lumens and protruding endothelial cells arranged in lobular fashion (Dunphy et al., 2015). Research has documented little information about cherry angioma etiology. But, as the patient ages, the risk of developing the disease increases by 75% in adults who are above 75 years of age, and the aging process may play a role in the pathogenesis of cherry angioma (Ball et al., 2017).

2.)   Glomeruloid hemangioma- is small dome-shaped papules, red in color or wine-red sessile or pedunculated papules, firm, papulonodules, subcutaneous bluish compressible tumors, or lesions with cerebriform morphology. They are located in proximal limbs and the truck, which range in size, measuring few millimeters to a centimeter in diameter, and is manifested, by a single or multiple blue-red papules (Kim, Park & Ahn, 2009).

3.)   Angiokeratoma corporis diffusum- Red to purple, hyperkeratotic and coalescing papules form most typically on the lower region of the trunk, buttocks, and thighs and is usually associated with Lyosomal storage diseases (Dunphy et al., 2015). The disease is identified by Ball et al (2017) as superficial ectatic vessels with epidermal proliferation.

Diagnoses/Client Problems of Image #2: 

1.)   Cherry angioma- People above the age of 30 are vulnerable to getting infected with cherry angioma disease and the risk increases numerically with age (Kim, Park & Ahn, 2009). As it forms in the lower papillary dermis, the Glomeruloid hemangioma is ruled out because it is vascular proliferation which occurs suddenly on the neck, head, extremities, and trunk region (Helm et al., 2017). Also, Angiokeratoma corporis diffusum was ruled out because all lab work enzymes were normal for the patient’s Lysosomal storage disease.

PLAN: No intervention is necessary. It could be removed for cosmetic reasons. 

Conclusion 

Cherry angioma is the most common dermatosis of vascular cause in the individual. Its rate in the scalp is extremely high, including men and women and it is progressively more in men over 30 years old. This soap note differential diagnosis has affirmed graphic #2 is cherry angiomas.

References 

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2017). Seidel's Physical Examination Handbook-E-Book: An Interprofessional Approach. Elsevier Health Sciences.

Dunphy, L. M., Winland-Brown, J., Porter, B., & Thomas, D. (2015). Primary care: Art and science of advanced practice nursing. FA Davis.

Helm, K. F., Marks, J. G., & Foulke, G. T. (2017). Differential Diagnosis in Dermatology. JP Medical Ltd.

Kim, J. H., Park, H. Y., & Ahn, S. K. (2009). Cherry angiomas on the scalp. Case reports in dermatology, 1(1), 82-86.