LAB ASSIGNMENT: DIFFERENTIAL DIAGNOSIS FOR SKIN CONDITIONS

LAB ASSIGNMENT: DIFFERENTIAL DIAGNOSIS FOR SKIN CONDITIONS

LAB ASSIGNMENT: DIFFERENTIAL DIAGNOSIS FOR SKIN CONDITIONS

Assessment

Tinea Barbae

Tinea barbae is an infection of the superficial dermatophyte that occurs on the bearded areas of the face and neck. It occurs almost solely in older adolescents and adult males (Kuruvella & Pandey, 2021). It most often affects farmers due to contact with an infected animal since a zoophilic organism causes it. Tinea barbae presents with a characteristic lesion, an inflammatory red nodule with pustules, and draining sinuses on the surface (Kuruvella & Pandey, 2021). The beard hairs are usually loose or broken, and removing the hair is easy and painless.

The pus-filled white masses affect the hair root and follicle (Singh et al., 2017). Tinea barbae is a priority differential diagnosis based on the patient’s findings of inflamed and red lumpy areas on the lower beards and red pustules with crusting around the beard hairs. Besides, the patient’s beard hairs are broken and easily plucked. The patient could have contracted the infection from an infected animal at the ranch. A direct microscopy culture will help in confirming the diagnosis.

Bacterial Folliculitis

Bacterial folliculitis is an inflammation of the hair follicle caused by infection, physical injury, or chemical irritation. It is primarily caused by Staphylococcus aureus (Jappa & Sameer, 2018). Bacterial folliculitis mostly occurs in skin areas exposed to occlusion, rubbing, and sweating, including the face, neck, axillae, and buttocks (Lin et al., 2018). Persons with superficial folliculitis usually have an acute onset that occurs with pruritus or mild discomfort.

Deep folliculitis typically has longer-standing lesions, and patients frequently report pain and, at times, suppurative drainage. Recurrent lesions can cause scarring and permanent hair loss. Superficial folliculitis presents with many small papules and pustules on an erythematous base pierced by a central hair, although the hair is not always visualized (Jappa & Sameer, 2018). Folliculitis is a differential diagnosis based on patient symptoms of pruritus and mild pain on the beard and pustules and crusting on an erythematous base.

Pseudofolliculitis Barbae:

Pseudofolliculitis barbae is a form of folliculitis involving the beard area. It is caused by infection with Staphylococcus aureus. It is a chronic inflammatory condition of follicular and perifollicular skin (Ogunbiyi, 2019). I presents with pustules, papules, and post-inflammatory hyperpigmentation. It occurs mostly in males of African and Asian descent. Patients report experiencing a painful eruption of acne after shaving (Ogunbiyi, 2019). It presents with an erythematous papule having a hair shaft in its center. The patient’s symptoms consistent with pseudofolliculitis barbae include pustules and erythematous at the beard area.

Reflection

The clinical experience has enlightened me on dermatological conditions affecting the beard area. I have learned that various bacteria or fungal infections can cause the conditions. Besides, I learned that the clinician should be keen during the examination to differentiate if a patient has papules (pimples with no visible pus) or pustules (pus-filled pimples), which helps differentiate the dermatological condition. If I were to repeat the assessment, I would perform a culture to identify the specific causative microbe.

References

Jappa, L. S., & Sameer, R. K. (2018). A clinical and bacteriological study of bacterial folliculitis. Panacea Journal of Medical Sciences, 8(2), 54-58. https://doi.org/10.18231/2348-7682.2018.0014

Kuruvella, T., & Pandey, S. (2021). Tinea Barbae. StatPearls [Internet].

Lin, H. S., Lin, P. T., Tsai, Y. S., Wang, S. H., & Chi, C. C. (2018). Interventions for bacterial folliculitis and boils (furuncles and carbuncles). The Cochrane Database of Systematic Reviews, 2018(8), CD013099. https://doi.org/10.1002/14651858.CD013099

Ogunbiyi, A. (2019). Pseudofolliculitis barbae; current treatment options. Clinical, cosmetic and investigational dermatology, 12, 241–247. https://doi.org/10.2147/CCID.S149250

Singh, S., Sondhi, P., Yadav, S., & Ali, F. (2017). Tinea barbae presenting as kerion. Indian journal of dermatology, venereology, and leprology, 83(6). https://doi.org/10.4103/ijdvl.IJDVL_1104_16

Week 9 Shadow Health Comprehensive SOAP Note Template

SUBJECTIVE DATA:

Chief Complaint (CC): Nasal congestion as well as itching for the last 5 days

History of Present Illness (HPI): .S is a 50-year-old male that came to the unit with complaints of nasal congestion, rhinorrhea, sneezing, itchy nose, postnasal discharge, and itching ears and nose for the last 5 days. The patient reported using Mucinex medication to help ease breathing but it has been associated with minimal effectiveness. The patient denied any history of pain or headache.

Medications: The patient currently uses Mucinex over-the-counter medication 1 tab orally on a daily basis.

Allergies: The patient denied any history of drug or food allergy. The patient reported history of seasonal allergies.

Past Medical History (PMH): The patient denied history of hospitalization and blood transfusion.

Past Surgical History (PSH): The client denied any history of surgery.  Sexual/Reproductive History: The client is married and has two children. He denies any history of sexually transmitted infections, impotence, urine incontinence, or urinary tract infections.

Personal/Social History: The patient is married with two children. The patient stopped smoking in 2012. He drinks alcohol on occasional basis. His highest level of education is university. He has a degree in business administration and works at a local supermarket as a manager. He reported that the symptoms of the disease had affected his sleeping patterns significantly.

Health Maintenance: He reported to engage in active physical activity on a regular basis. Immunization History: The immunization records of the client were up to date.

Significant Family History: The parents of the patient are both alive. His father was diagnosed with diabetes in 2016 and has been on treatment. His mother was diagnosed with hypertension in 2020 and is on treatment. The patient is the second born in a family of three. His siblings are all alive and healthy.

Review of Systems:

General: The patient appeared well groomed for the occasion. He was oriented to time, place, and self. He denied fevers, fatigue, or chills. The patient reported being tired due to lack of enough sleep secondary to the symptoms of the health problem

HEENT: The patient denied headaches. The patient reported that his eyes are

itchy and red. There were no changes in the vision. The tympanic membranes are intact, with absence of ear drainage of changes in hearing. The patient reported nasal congestion, itchy, with pale and boggy nasal mucosa. There was clear nasal drainage with slightly enlarged nasal turbinates. There was absence of tonsillitis. The throat was mildly erythematous.

Respiratory: The trachea was midline without any deviation or lymphadenopathy.

Cardiovascular/Peripheral Vascular: The patient denied chest pain, palpitations, discomfort, or edema.

Gastrointestinal: The patient denied nausea, vomiting, diarrhea, and abdominal distention.

Genitourinary: The patient denied dysuria, oliguria, polyuria, or frequent urination.

Musculoskeletal: The patient denied joint or muscle pain.

Neurological: The patient denied headache, changes in gait, body imbalance, and loss of sensations.

Psychiatric: The patient denied  any history of psychiatric illnesses in the family.

Skin/hair/nails: The patient denied skin rash, changes in skin color, and itching.

OBJECTIVE DATA:

Physical Exam:

Vital signs: BP 110/76 P-80 Temp 37.6 RR-20 Weight 58 kg Height 6’1 BMI 24.8

General: The patient appeared well groomed for the occasion. He was oriented to time, place, and self.

HEENT: The patient had red eyes. Vision acuity was normal with absence of pallor and drainage from the eyes. The tympanic membranes are intact, with absence of ear drainage of changes in hearing. The patient had pale and boggy nasal mucosa. There was clear nasal drainage with slightly enlarged nasal turbinates. There was absence of tonsillitis. The throat was mildly erythematous.

Neck: Carotids no bruit, jvd or thyromegally

Chest/Lungs: Presence of normal lung sounds, absence of rarels and wheezing. The patient does not use respiratory muscles in breathing.

Heart/Peripheral Vascular: RRR without murmur, rub or gallop

Abdomen: Absence of abdominal distention, normal bowel movements heard, absence of organomegally.

Genital/Rectal: Patient declined for this exam

Musculoskeletal: Symmetric muscle development with absence of abnormal gait or fractures

Neurological: Absence of muscle paralysis, loss of sensation, and movements

Skin: No edema, clubbing, or cyanosis; no palpable nodes

Diagnostic results: Positive skin test to pollen

ASSESSMENT:

Differential Diagnosis

Allergic Rhinitis: The first differential diagnosis for the patient is allergic rhinitis. As noted initially, allergic rhinitis is a respiratory condition that develops following an individual exposure to an allergen. The symptoms associated with allergic rhinitis include sneezing, nasal congestion, rhinorrhea, and itchy eyes. The symptoms developed due to IgE mediated reactions against the allergens (Okubo et al., 2020). Allergic rhinitis is the primary diagnosis for the patient due to the positive skin test.

Non-allergic rhinitis: Non-allergic rhinitis is the other possible condition affecting the client. Patients present with symptoms such as nasal congestion, rhinorrhea, sneezing, and itchy eyes among others. However, patients do not have history of allergic reactions to allergens (Zheng Ming et al., n.d.). This is the least diagnosis for the client in the case study because he has history of seasonal allergy.

Sinusitis: sinusitis refers to a condition where the paranasal sinuses are inflamed. Sinusitis is attributed to causes such as fungal, viral or bacterial infections and allergic reactions. Patients with sinusitis experience symptoms such as nasal congestion, headache, rhinorrhea, fever, and facial pain (Little et al., 2018). Sinusitis is however, the least possible condition due to the absence of signs and symptoms associated with infections.

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Flu/Common cold: Common cold is the other potential diagnosis. Common cold is an acute viral infection affecting the upper respiratory system. It may involve sinuses, larynx or the pharynx. Patients experience symptoms such nasal drainage, malaise, fever, and headache among others. It is however the least likely due to the absence of signs and symptoms of infection (Sadeghirad et al., 2017).

Sore throat: Sore throat is the other potential diagnosis for the patient. Patients experience pain in the pharynx on swallowing. Sore throat is largely attributed to viral infections. The patient however is least suffering from sore throat because of the absence of signs and symptoms of infection (Mahalingam et al., 2020).

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

References

Little, R. E., Long, C. M., Loehrl, T. A., & Poetker, D. M. (2018). Odontogenic sinusitis: A review of the current literature. Laryngoscope Investigative Otolaryngology, 3(2), 110–114. https://doi.org/10.1002/lio2.147

Mahalingam, N. V., Abilasha, R., & Kavitha, S. (2020). Awareness of symptomatic differences COVID-19, sars, swine flu, common cold among dental students. International Journal of Research in Pharmaceutical Sciences, 11(Special Issue 1). https://doi.org/10.26452/ijrps.v11iSPL1.3431

Okubo, K., Kurono, Y., Ichimura, K., Enomoto, T., Okamoto, Y., Kawauchi, H., Suzaki, H., Fujieda, S., Masuyama, K., & Allergology, T. J. S. of. (2020). Japanese guidelines for allergic rhinitis 2020. Allergology International, 69(3), 331–345. https://doi.org/10.1016/j.alit.2020.04.001

Sadeghirad, B., Siemieniuk, R. A. C., Brignardello-Petersen, R., Papola, D., Lytvyn, L., Vandvik, P. O., Merglen, A., Guyatt, G. H., & Agoritsas, T. (2017). Corticosteroids for treatment of sore throat: Systematic review and meta-analysis of randomised trials. BMJ, 358, j3887. https://doi.org/10.1136/bmj.j3887

Zheng Ming, Wang Xiangdong, Ge Siqi, Gu Ying, Ding Xiu, Zhang Yuhuan, Ye Jingying, & Zhang Luo. (n.d.). Allergic and Non-Allergic Rhinitis Are Common in Obstructive Sleep Apnea but Not Associated With Disease Severity. Journal of Clinical Sleep Medicine, 13(08), 959–966. https://doi.org/10.5664/jcsm.6694

SUBJECTIVE DATA:

Chief Complaint (CC): “Stretch marks.” (Image 2)

History of Present Illness (HPI): W.T. is a 26-year-old AA female presenting to the dermatologic clinic with complaints of stretch marks. She is concerned about her appearance and wishes to know if there is any cream she can use to reduce the appearance of stretch marks. She is pregnant, and the gestation by date (GBD) is 32 weeks. The stretch marks began appearing when she was about 22 weeks pregnant, and they have increased in number and size as the pregnancy progressed. She reports having used cocoa butter, shea butter lotions, and various stretch marks creams, but they have been ineffective.

Medications: Iron and Folic acid Supplements

 

Allergies: Allergic to Penicillin- causes a rash.

 

Past Medical History (PMH): No chronic illnesses.

Past Surgical History (PSH): Tonsillectomy at 6 years.

Sexual/Reproductive History: Para 0+0, Gravida-1; No history of STIs or gynecological disorders. Had UTI at 16 weeks GBD but was successfully treated with Nitrofurantoin. She was previously on IUD.

 

Personal/Social History: W.T. is married and lives with her husband in Baltimore, MD. She has a Diploma in Secretarial studies and works as a corporate secretary. Her hobbies are baking and traveling. She reports having about six small meals and about 3L of water daily. She used to smoke ½ PPD and drink 2-3 glasses of vodka on her off days before getting pregnant. She denies currently taking alcohol, smoking, or using any drug substances. The patient states that her husband and elder sister are her support system.

Health Maintenance: The patient reports attending antenatal checkups and adheres to the daily Iron and Folic Acid supplements.

 

Immunization History: Her immunization status is up to date. She had a TT2 booster in the last antenatal visit. The last Flu shot was 8 months ago.

Significant Family History: The maternal grandmother has Rheumatoid arthritis and HTN. The father was recently diagnosed with diabetes. Her siblings are alive and well.

 

Review of Systems:

General: Denies fever, generalized weakness, or chills.

HEENT: Denies eye redness, excessive tearing, blurred vision, nasal secretions, or swallowing difficulties.

Respiratory: Denies breathing difficulties, wheezing, or coughing.

Cardiovascular/Peripheral Vascular: Denies edema, chest tightness, palpitations, or exertional dyspnea.

Gastrointestinal: Reports occasional nausea and vomiting. Denies abdominal pain, heartburn, diarrhea, or constipation.

Genitourinary: Reports urine frequency and increased PV discharge. Denies foul-smelling discharge, lower abdominal pain, or urinary urgency.

Musculoskeletal: Denies back pain, joint stiffness, or pain.

Neurological: Negative for headaches, dizziness, or muscle weakness.

Psychiatric: Negative for psychotic, mood, or anxiety symptoms.

Skin/hair/nails: Reports stretch marks. Denies itching, burning sensation, rashes, bruising, or brittle nails

 

OBJECTIVE DATA:

Physical Exam:

Vital signs: BP-122/78; HR-80; RR-16; Temp-98.4; HT-5’4; WT- 154 lbs.

General: AA female client in no distress. She is alert and oriented x3.

HEENT: Head is symmetrical; Eyes: Sclera is white; Conjunctiva is pink; PERRLA; Ears: Intact and shiny TMs

Neck: Symmetrical and Supple. Thyroid gland normal on palpation.

Chest/Lungs: Uniform chest expansion. Smooth respirations; Lungs clear on auscultation.

Heart/Peripheral Vascular: No edema or neck vein distension. Regular heart rate and rhythm; S1 and S2 present; No murmurs.

Abdomen: Gravid abdomen; The abdominal skin is stretched with marked striae. Linea nigra present; Normoactive BS; FHR-142b/min; Gravid mass on palpation; No tenderness on palpation; No organomegaly.

Genital/Rectal: Normal female genitalia. Intact anal sphincter.

Musculoskeletal: Active ROM; No joint deformities.

Neurological: Clear speech; CNs are intact; Muscle strength- 5/5; Upright posture; Steady gait.

Skin: Flat dark streaks on the abdomen. The dark streaks are raised, 1-10 mm wide, and the length varies at 1-5 cm. A dark vertical line runs from the diaphragm to the pubic area.

 

Diagnostic results: No tests were ordered.

 

ASSESSMENT:

Striae gravidarum: Striae gravidarum are stretch marks that appear during pregnancy. They are caused by thin tears in the dermal collagen. They appear as flat red or hypopigmented stripes that become raised, longer, wider, and violet-red (Abbas et al., 2018). The patient has dark flat streaks on the abdomen that first occurred during pregnancy, which align with Striae gravidarum.

Anetoderma: It is characterized by flaccid, well-circumscribed areas of slack skin. Sac-like protrusions can sometimes be observed in some lesions. It is attributed to the loss of elastic fibers within the dermis (Genta et al., 2020). Histopathology is necessary to confirm or rule out Anetoderma to determine if elastic tissue is lost in the dermis.

Lichen sclerosus: This is a rare autoimmune skin condition characterized by skin atrophy and hypopigmentation. It commonly affects genital skin. It typically begins as a sharply demarcated erythema that progresses into thin, hypopigmented, ivory-white, and sclerotic plaques.

The plaques are surrounded by a purple, red, or violet border (Singh & Ghatage, 2020). The hypopigmented streaks make this a differential diagnosis. However, the patient has no plaques, and the streaks are not in the genital area ruling Lichen sclerosus as the primary diagnosis.

Elastotic striae: This is a rare skin condition that manifests as asymptomatic atrophic yellow lines on the thighs, mid or lower back, arms, or breasts. It manifests clinically with asymptomatic, numerous, yellowish, elevated, irregularly indurated, striae-like lines or bands spread horizontally across the lower and middle part of the posterior trunk (Palaniappan et al., 2023). The patient has raised irregular streaks, but they are not in the posterior trunk, making this an unlikely primary diagnosis.

Scarring: Scars present as raised, firm nodules or plaques, usually at sites of previous trauma (Barone et al., 2021). However, the patient has no history of abdominal trauma, which rules out scarring as the cause of the hypopigmented streaks.

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

References

Abbas, A. M., Kamel, F. M., & Salman, S. A. (2018). Clinical significance and treatment of striae gravidarum during pregnancy: a review article. International Journal of Reproduction, Contraception, Obstetrics and Gynecology, 8(1), 368. doi:10.18203/2320-1770.ijrcog20185454

Barone, N., Safran, T., Vorstenbosch, J., Davison, P. G., Cugno, S., & Murphy, A. M. (2021). Current Advances in Hypertrophic Scar and Keloid Management. Seminars in plastic surgery, 35(3), 145–152. https://doi.org/10.1055/s-0041-1731461Lokhande, A. J., & Mysore, V. (2019). Striae Distensae Treatment Review and Update. Indian dermatology online journal, 10(4), 380–395. https://doi.org/10.4103/idoj.IDOJ_336_18

Genta, M. P., Abreu, M. A. M. M., & Nai, G. A. (2020). Anetoderma: an alert for antiphospholipid antibody syndrome. Anais brasileiros de dermatologia, 95(1), 123–125. https://doi.org/10.1016/j.abd.2019.04.010

Palaniappan, V., Selvaarasan, J., Murthy, A. B., & Karthikeyan, K. (2023). Linear focal elastosis. Clinical and Experimental Dermatology, 48(3), 175-180. https://doi.org/10.1093/ced/llac071

Singh, N., & Ghatage, P. (2020). Etiology, Clinical Features, and Diagnosis of Vulvar Lichen Sclerosus: A Scoping Review. Obstetrics and gynecology international, 2020, 7480754. https://doi.org/10.1155/2020/7480754