Differential Diagnosis For Skin Conditions Nurs 6512

Differential Diagnosis For Skin Conditions Nurs 6512

SUBJECTIVE DATA:

Chief Complaint (CC): “My left thumbnail has been having a vertical split at the center for the last three months”

History of Present Illness (HPI): AD is a 34-year-old white male who presents with a vertical split on his left thumbnail. He states that it started four months ago. He reports he tends to habitually rub the thumb’s nail fold using the tip of the second digit. He also states that he has frequented a manicurist in the last four months who have been pushing back his cuticle during the manicure. His nail has a crack that extends laterally and looks like the branches of a fir tree. He denies erythema or warmth and no other fingernails are affected. The finger is painless. 

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Medications: None

Allergies:  No known drug or food allergies.

Past Medical History (PMH):

1. Tonsilitis
2. Appendicitis

Past Surgical History (PSH):

1. Tonsillectomy
2. Appendectomy

Sexual/Reproductive History:

The patient is a heterosexual and he reports no reproductive issues or risky sexual behavior. He is married with one kid. He has no history of STIs.

Personal/Social History:

The patient is a real estate agent who lives with his wife and kid. Patient denies smoking, ETOH, or consuming any illicit substance. He states that he exercises three times a week and maintains a healthy diet.

Health Maintenance:

AD presents annually for a routine physical exam. He reports bloodwork 2 years ago at an annual exam.

Immunization History:

Immunizations up to date and had a flu vaccine two months ago. He had a Tdap in 2018.

Significant Family History:

Father alive 67 HTN, mother alive 60 healthy. He is the only sibling and he reports that his daughter is in good health with no significant health history.

Review of Systems:

General: The patient denies fever or chills, fatigue, or decreased appetite. He denies difficulty sleeping, night sweats, malaise, chills, or unexplained weight changes.  

HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia, or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, and congestion. THROAT: Denies throat or neck pain, hoarseness, or difficulty swallowing.

            Respiratory: The patient denies shortness of breath, cough, or hemoptysis.

Cardiovascular/Peripheral Vascular: The patient denies arrhythmia, chest pain, palpitations, heart murmur, or SOB.

Gastrointestinal: The patient denies abdominal pain or discomfort. He denies flatulence, nausea, vomiting, or diarrhea.

Genitourinary: Pt denies hematuria, dysuria, or change in urinary frequency. He denies difficulty starting/stopping a stream of urine or incontinence.

            Musculoskeletal: Pt denies edema, weakness, or joint pain of extremities B/L.

Neurological: Denies headache and dizziness, LOC or history of tremors or seizures.

Psychiatric: Pt denies a history of anxiety or depression. He reports no sleep disturbance, delusions, or mental health history. He denied a suicidal/homicidal history.

Skin/hair/nails: The patient denies rash, petechiae, pruritus, or abnormal bruising/bleeding. He complains of a vertical split on his left thumbnail.

OBJECTIVE DATA:

            Physical Exam:

Vital signs: Temp: 98.67 °F, Pulse: 85 and regular, BP: 118/79 mm hg left arm, sitting, regular cuff; RR 17 non-labored; Ht- 6’0”, Wt 170 lb, BMI 23.1.

General: AD is a well-groomed White male of well nutritional status who is cooperative and answers questions appropriately. Alert and oriented x 3.

HEENT: Normocephalic/atraumatic. Eyes: PERRLA. Conjunctiva pink with no scleral jaundice. Mouth: Moist mucosa, No lesions, inflammation, or exudate to the oral mucosa, tongue, or gum line. Ears: No lesions, scars, papules or nodules noted on the helix.

Neck: Supple and trachea midline. No thyromegaly

Chest/Lungs: Equal and bilateral chest rise, breathing unlabored with good respiratory effort no accessory muscle use. No tenderness on palpation of sternum, anterior or posterior thorax. resonant percussion over all lobes. Lung sounds clear on inspiration/expiration, anterior and posterior with no rhonchi, crackles, or wheezing with no areas of diminished breath sounds.

Heart/Peripheral Vascular: RRR. S1 and S2 are normal. No murmurs or bruits were noted. Chest non-tender, no visible heaves, and JVO non-elevated.

Abdomen: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation

Genital/Rectal: No bladder distention, suprapubic pain, or CVA tenderness.

Musculoskeletal: 2+ radial and dorsalis pulses. No edema, cyanosis, or clubbing was noted. The patient has a full ROM with no pain, swelling, or tenderness.

Neurological: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.

Skin/nails: Warm, dry, and intact. The patient has a feathered, central, longitudinal ridge with a fir tree pattern on his left thumb. He has transverse ridges, parallel and angled towards the nail fold. He also has macrolunulae.

ASSESSMENT:

Differential Diagnosis

1. Median nail dystrophy- Refers to a split in the midline of the nail that starts from the cuticle. It affects the thumbs mostly and presents with a longitudinal groove in the central portion of the nail plate that starts at the proximal nail fold (Ball et al., 2019). The groove has small grooves that connect to it in an oblique fashion resulting in an inverse “fir-tree” pattern (Khodaee et al., 2020). It is caused by a temporary defect in the matrix that interferes with nail formation. Harsh trauma to the nail and recurrent self-inflicted trauma is the major cause of the disorder. The patient reports habitually rubbing his thumb’s nail fold using his index finger and visiting a manicurist who pushes his cuticle during a manicure. The presentation and the patient’s report confirm the diagnosis.
2. Habit-tic deformity– It is also a form of nail dystrophy that is linked to habitual external trauma to the matrix. It affects the thumbs and presents as central depression and transverse, parallel ridging that runs from the nail fold to the distal edge of the nail (Sathyapriya et al., 2020). The transverse depression projects a “washboard” configuration. Some patients also report redness and swelling along the proximal nail fold (Dains et al., 2019). The diagnosis is ruled out because the current patient has a fir-tree pattern rather than transverse parallel ridges.
3. Trachyonychia- Refers to rough nails. It can present as either opaque or shiny. In an opaque trachyonychia, the nail plate has longitudinal ridges while the nails appear opaque, rough, and with a “sandpapered” appearance (Sathyapriya et al., 2020). Shiny trachyonychia on other hand has numerous small pits with longitudinal and parallel lines. The nails have a shiny appearance. The disorder affects all the nails. It is ruled out because the patient does not record any presentation that can be said to be sandpapered or shiny.
4. Subungual skin tumors- Refers to skin cancer that affects the skin under the nails. It results in brown-black discolorations of the nail bed that occurs as either a streak or irregular pigmentation (Sathyapriya et al., 2020). The discoloration usually progresses to thickening, splitting, or destruction of the nails. It is however accompanied by pain and inflammation. The current patient reports no pain or inflammation neither does he have any pigmentation ruling out the diagnosis.

Primary Diagnosis

1. Median nail dystrophy

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Skin, hair, and nails: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

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.

Khodaee, M., Kelley, N., & Newman, S. (2020). Median nail dystrophy. CMAJ, 192(50), E1810-E1810. https://doi.org/10.1503/cmaj.201002

Sathyapriya, B., Chandrakala, B., Heba, A., & AnubharathyV, G. S. (2020). Deformities, Dystrophies, and Discoloration of the Nails. European Journal of Molecular & Clinical Medicine, 7(5), 2020. https://www.ejmcm.com/article_4114_44f01b00119c36ca34c67eea5116ed45.pdf