health assessment

A 63-year-old woman comes to your office because she’s been forgetting things…a young mother comes in concerned because her baby fails to make eye contact and is unresponsive to touch…a teenager comes in and a parent complains that the teen obsessively washes his hands.

An array of neurological conditions could be causing the above symptoms. When assessing the neurologic system, it is vital to formulate an accurate diagnosis as early as possible to prevent continued damage and deterioration of a patient’s quality of life.

This week, you will explore methods for assessing the cognition and the neurologic system.

A 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools.

Imagine not being able to form new memories. This is the reality patients with anterograde amnesia face. Although this form of amnesia is rare, it can result from severe brain trauma. Anterograde amnesia demonstrates just how impactful brain disorders can be to a patient’s quality of living. Accurately assessing neurological symptoms is a complex process that involves the analysis of many factors.

In this Case Study Assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

· By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.

· Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

With regard to the case study you were assigned:

· Review this week’s Learning Resources, and consider the insights they provide about the case study.

· Consider what history would be necessary to collect from the patient in the case study you were assigned.

· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

· Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

The Case Study Assignment

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. 

A 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools.

Episodic/Focused SOAP Note Template

 

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

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. Use LOCATES Mnemonic to complete your HPI. 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

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

O.

Physical exam: 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. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

A

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Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

P.
  

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

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.

© 2019 Walden University

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Running head: SKIN CONDITIONS AND DIFFERENTIAL DIAGNOSIS 1

SKIN CONDITIONS AND DIFFERENTIAL DIAGNOSIS 7

Skin Conditions and Differential Diagnosis

Adesola Turner

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. 

Psych: He denies suicidal history. No history of depression or anxiety. The report shows he is not insomniac, psychological disorders or delusions. 

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.