Differential Diagnosis for Skin Conditions
Purpose: To assess skin conditions: Case Study Picture #2 for Cherry Angioma
Patient Initials: G.G. Age: 42 Gender: Male Ethnicity: non-Hispanic
SUBJECTIVE DATA
Chief Complains: “My chest and abdomen has red and round rashes that make me uncomfortable” Picture #2
History of Present Illness (HPI): G.G is a 42 year-old-non Hispanic male who presents to the clinic with a major complaint of red rashes. The client saw the first irregular/red papule four weeks ago, and they have to keep multiplying around his anterior chest and abdomen. He denies any family history of such lesions and an unremarkable medical history. G.G. reports that occasionally the red papules bleed when he wears certain clothes. The client rates the papules’ pain as 0/10 on a scale of 0-10 10 being the worse pain and 0 being no pain. G. G denies pruritis in the affected areas. He has never used medications for treating the rashes
Medications:
Cetirizine 10mg P.O. prn- seasonal allergies
Colace 100mg PO prn- GERD
Senna S. tablet P.O. prn- constipation
Abatacept 500mg injection once a week- arthritis
Metformin 500 orally once a day- Type 2 diabetes
Cyclosporine 50mg P.O.- kidney transplant
Allergies
Seasonal allergies- sneezing, runny noses, and itchy eyes
Penicillin allergies- itching, skin rash, hives, wheezing, and runny nose
Denies latex allergies and food allergies
Past medical history
Type 2 diabetes diagnosed at the age of 24
Gastroesophageal reflux diseases (GERD) diagnosed six months ago- well managed
Arthritis diagnosed a two months
Occasional constipation
Past Surgical History (PSH): Appendectomy at the age of 8, Kidney transplant at the age of 38
Reproductive History: Heterosexual with a monogamous family of one wife and three children. No history of sexually transmitted infections
Family History: Family history of asthma and diabetes. No family history of melanoma. His 21-year-old daughter is asthmatic and allergic to peanuts
Social History: G.G. works as a petroleum plant engineer and is often exposure to bromine gas. He occasionally drinks with his friends during the week. He takes 2-3 drinks in a single sitting. Denies smoking cigarettes due to his asthmatic condition
Immunization history:
Childhood vaccinations are up to date, last flu vaccine- December 2020, last T-dap- November 2018
Lifestyle: G.G is an engineer working in a big petroleum plant. He lives with his wife, mother-in-law, and three children in a storey building. He has healthcare insurance that covers the medical bills of his immediate family members. G.G. exercises frequently and is a fun of riding a bicycle. The client likes visiting Asian nations such as Iraq for exploration of his petroleum field. The client has a reliable source of support, including his immediate family.
Review of the systems
General: The client reports fatigue or tiredness. Denies fever but reports having weight loss and frequent night sweats
HEENT: head; denies head injury or trauma, ears; denies ear pain or ear drainage, eyes; reports blurry visions and often wears corrective glasses, reports itchy eyes when he takes penicillin substances, nose; reports runny nose when exposed to allergic reactions, throat; denies sore throat, dental problems or changes in smell sensations. His last annual dental exam was 19/11/2019
Neck: No neck pain or neck stiffness. No history of degenerative disc disease
Skin, hair, and nails: No history of skin cancer, reports red papules on the chest and abdomen skin, denies hair loss, reports skin reactions when exposed to certain chemicals, denies sunburns, showers with shampoos daily and oils his skin with cosmetics, denies dry skin. Uses trimmer on toenails and figure nails twice a week
Gastrointestinal: Reports regular soft bowel sounds present on the abdomen
Respiratory: Reports wheezing when exposed to seasonal allergies
Cardiovascular: Denies chest pain, shortness of breath, and edema
Musculoskeletal: Reports a history of arthritis, muscle pain, muscle swelling, or joint pain
Psychiatric: No history of depression or anxiety, denies suicidal attempts, difficulty concentrating, or lack of sleep
Hematologic: History of blood transfusions during his kidney transplant
Endocrine: Denies heat or cold intolerance or changes in gloves or shoe sizes
Allergic: Reports penicillin allergies and seasonal allergies
(Ball et al., 2019)
OBJECTIVE DATA:
Physical exam
Vital signs: BP 117/65, H.R.: 96, R.R.: 16, Temp 97.6F, Ht 5’7, wt 200 pounds, BMI 31.3, Pain 0/10
General: G.G. is A&O*3, is a good historian and appears to be healthy and in good hygiene. He is in no apparent distress. He is obese
HEENT: head; symmetrical round, smooth and round without bumps or lesions, smooth and symmetric face, eyes, Snellen Chart Acuity O.S. 20/20, O.D. 20/20, eyelids are in normal position, no discharge redness, or crusting noted on lid margins, white sclera with no redness or lesions, transparent cornea with no opacities, round and evenly colored irises. Ears; equal in size bilaterally with smooth skin, no nodules, lumps, or lesions, nontender on palpitation, nose; symmetrical and large nose, able to sniff on each nose string, no purulent drainage observed, nontender frontal and maxillary sinuses, throat; pink and symmetric tonsillar pillars, mouth; smooth, pink lips without lesions, moist pink buccal mucosa without exudates.
Neck: Symmetric neck positioned at the center of the head, no bulging masses, full range of motion, nonvisible thyroid gland palpable when swallowing, and nonpalpable lymph nodes
Skin, hair, and nails: dry, warm, elastic, pink skin. A 4-inch scar of the old appendectomy is observed on the right lower abdomen. Multiple 3-5mm raised red, tender lesions on the anterior chest and abdomen. No skin cyanosis or palpable masses Brown hair on the chest, normal hair distribution on perineum and scalp, and no hair on the legs. Smooth, hard and immobile nails, pink nail beds without clubbing, smooth cuticles.
Chest/lungs: Symmetric chest expansions, no tenderness or pain on palpitation, symmetric tactile fremitus, relaxed and even respirations, less than transverse diameter anteroposterior, resonant tones overall lungs fields on percussion, no vesicular breath sounds on auscultation, no adventitious sounds present
Heart/Peripheral: No bruits over carotids auscultated, equal carotid pulses bilaterally, 2+, elastic, regular rhythm, audible S1, and S2
Abdomen: Symmetrical and flat abdomen with no lumps or bulges observed, generalized tympanic on the four quadrants. Abdomen skin has red rashes, hair around the umbilicus, and surrounding area free of swelling or masses.
Genitalia: Normal public hair growth, public hair is free of infestation and excoriation. No swelling or masses observed on the scrotum, skin appears darkly pigmented, no masses, rashes, swelling on the genitalia
Musculoskeletal: Full ROM with no pain, tenderness, or clicking. Normal curves of lumbar, thoracic, or cervical spine observed
(Ball et al., 2019)
ASSESSMENT
Lab tests and Results
Labs: Complete blood count, WBC 10000, HgB 10.9
Diagnostics: Skin lesion biopsy- Revealed capillaries made of neovascular vessels with a lobular patterned endothelium and thin lumen in the papillary dermis (Ball et al., 2019)
Differential Diagnosis:
- Cherry Angiomas
- Angiokeratoma
- Metastatic carcinoma
- Pyogenic granuloma
- Venous lake
Cherry angiomas: These are the most common form of acquiring vascular proliferation of the skin. Cherry angiomas are more prevent among the people aged 40 years and above, and the number of lesions increases with age. Clinically, early lesions appear as flat red macules that look in petechiae. As they develop to become 1-5mm red papules. These lesions are usually asymptomatic, but they may bleed with stress. They mostly occur on the proximal extremities and trunk and rarely occur on body parts such as legs, hands, or face. Both subjective and objective data supports cherry angiomas as the primary diagnosis for the client. In essence, the client reporhttps://essaygroom.com/discussion-forum-unit-four-differential-analysis/ted lesions that are painless but bleed on clothing. According to Corazza et al. (2019), some of the risk factors for cherry angiomas include exposure to some chemicals, kidney transplant, as well as medications such as cyclosporine reported. It is also assumed that the lesions develop as a result of the aging process and tend to be large in diabetic patients. Besides, the biopsy test reveals capillaries on the endothelium and papillary dermis which is an indication of cherry angiomas
Angiokeratoma: These are also small red to purple papules with a rough, scaly surface just like cherry angioma. They are made up of dilated capillaries and may even bleed if accidentally scratched. Angiokeratoma of Fordyce is commonly found on the scrotum, around the penis, and in the inner thighs. Mostly they occur in patients aged 40 years and above and more prevalent in men than women (Dains et al., 2019). They are usually symptomless and maybe notice when they bleed after intercourse. The diagnosis is ruled out, given the location of papules in the chest and abdomen. The objective data reports no papules around the genitalia.
Metastasis carcinoma: This is the stage IV cancer that occurs when cells spread through the lymph vessels or bloodstream to another part of the body and form new tumors. Most cancers metastasize on the nearby lymph nodes, and cancer cells may tend to spread to the lungs, brain, or liver. Metastasis carcinoma can cause melanoma, which is the most dangerous type of skin cancer that can spread to the lungs and brain (Corazza et al., 2019). The diagnosis is ruled out because the client denied any history of skin cancer, and the biopsy test did not reveal any presence of cancer.
Pyogenic granuloma: This is a common reactive proliferation of capillary blood vessels that presents as red minced meat-like surface. They are common vascular tumor that occurs in all ages affecting both mucous membrane and skin. Granuloma can arise spontaneously within capillary malformations or in sites of injury. Most of the tumors occur as single lesions, and multiple tumors may be due to adverse effects of melanoma treatment with medications such as vemurafenib (Wollina et al., 2017). Given that the patient did not report melanoma diagnosis or treatment that can cause multiple pyogenic granulomas, it is ruled out as the primary diagnosis.
Venous lake: This is a common bluish soft papule due to vascular dilation mostly observed on the lower lip. Venous varix is often caused by aging and weakening of blood vessels, causing vessel dilation. They are more prevalent on the heavily sun-damaged skin due to ultraviollight induced changed. Venous lakes are often solitary and mostly occur on the head, neck, or lips. They present a comprehensible, soft, and dark blue papules of 1 to 4 mm in size (Sacks et al., 2018). Given the location, size, and color of the papules presented by the patient, venous lake is ruled out as the primary diagnosis.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Corazza, M., Dika, E., Maietti, E., Musmeci, D., Patrizi, A., &Borghi, A. (2019). Eruptive cherry angiomas and skin melanoma: a fortuitous association?. Melanoma research, 29(3), 313-317.
Dains, J. E., Baumann, L. C., &Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Sacks, J. D., Heithaus, E., Ghazi, A., & Cura, M. (2018, October). Vascular lakes after doxorubicin drug-eluting bead chemoembolization with histologic analysis. In Baylor University Medical Center Proceedings (Vol. 31, No. 4, pp. 541-542). Taylor & Francis.
Wollina, U., Langner, D., França, K., Gianfaldoni, S., Lotti, T., & Tchernev, G. (2017). Pyogenic Granuloma – A Common Benign Vascular Tumor with Variable Clinical Presentation: New Findings and Treatment Options. Open access Macedonian journal of medical sciences, 5(4), 423–426. https://doi.org/10.3889/oamjms.2017.111