EENT Has worn glasses since 1992 and denies any double vision or history of

Eent has worn glasses since 1992 and denies any

This preview shows page 13 - 15 out of 15 pages.

EENT: Has worn glasses since 1992 and denies any double vision or history of cataracts. No loss of hearing or changes in sense of smell, denies ear pain, nasal drainage or chronic sinus infections. No dentures or appliance and stated that his last dental exam was about 6 months ago. Cardiovascular: His heart attack 3 years ago resulted in the placement of 2 stents to the right coronary artery. He denies any chest pain, palpitations, dyspnea, No history of arrhythmias or murmurs. His last EKG was about a year ago. Genitourinary: Has been experiencing hesitancy with urination but denies any hematuria, incontinence, penile discharge, or erectile dysfunction. He has never had a PSA test.
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Integumentary: Complains about the pruritis of the scaly plaques on his arms and is concerned about the cherry red papules on his torso. Denies any other rashes, pruritis, or bruising. No history of skin cancer or other lesions. Objective Data PHYSICAL EXAMINATION General: Mr. Smith is a well groomed Caucasian male of well nutritional status who is cooperative and answers questions appropriately. Alert and oriented x 3. Vital signs: Temperature 98.6, orally; BP 132/83, pulse 72, R 16 and regular. He weighs 194 pounds and is 5’8” with a BMI of 29.5. Skin: Dry, scaly, salmon colored plaques are present on the posterior aspects of both forearms. Cherry red discoid papules are present on torso. Skin surrounding the lesions is normal in appearance without redness or edema. Skin turgor is normal with no pallor or jaundice. HEENT: normocephalic, PERRLA Neck: supple, full ROM. No JVD or bruit. Chest/Lungs: Breath sounds clear and regular bilaterally. Cardiovascular: Heart regular rate and rhythm. No murmurs. Distal pulses 2+. No peripheral edema. Abdomen: Soft, nontender. No distention, masses, or organomegaly. Normoactive bowel sounds present x4 quadrants. Genital/rectal: External genitalia reveals circumcised male with normally decended testes. Prostate is non-tender and not enlarged. Musculoskeletal: Fully weight-bearing. Full ROM in all extremities. Neurological: A&O x3, cooperative. CN II-XII intact. DTRs 2+ and symmetrical bilaterally. Assessment Differential diagnosis (Image # 5) 1. Psoriasis 2. Seborrheic dermatitis 3. Atopic dermatitis 4. Tinea Corpis
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Differential diagnosis (Image #2) 1. Cherry angioma 2. Angiokeratoma 3. Keratosis pilaris Plan Image #5 will be treated as psoriasis. Psoriasis, as pictured, is characterized by circumscribed, dry, silvery, salmon colored, scaling papules with lesions frequently occurring on the back, buttocks, exterior services of extremities, and the scalp (Ball, Dains, Flynn, Solomon, & Stewart, 2015). Image #2 will be treated as cherry angiomas. Ball, Dains, Flynn, Solomon, & Stewart, (2015) explain that cherry angiomas are characterized by tiny, bright ruby-red, round papule that may be present in essentially everyone over age 30 and increase in abundance with age. 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. Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
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