NURS 6512 Differential Diagnosis for Skin Conditions

NURS 6512 Differential Diagnosis for Skin Conditions

NURS 6512 Differential Diagnosis for Skin Conditions

SUBJECTIVE DATA:

Chief Complaint (CC): Presence of a rash that has blisters that starts from the chest radiating to the armpit and also on the patient’s back

History of Present Illness (HPI): William Mendel is a 30 year old Black African American who has a rash that is similar to blisters that has covered his chest and back radiating to the armpit. He states the onset of the onset of the rash was a week ago and at the site he has an itching sensation as well as him experiencing a burning pain and some tingling. He informs that the pain is at 8/10 and at palpation it’s at 10/10.

Medications:

• Paracetamol over the counter two tablets every 6 hours for pain.
• Diphenhydramine over the counter 25 mg 1 tablet thrice daily for the itching.
• Hydrocortisone over the counter that is topical used when needed to also deal with the itching.
• Flomax 0.4mg

Allergies:

The patient has no known food or drug allergies.

Past Medical History (PMH):

1.) Gallstones

2.) Varicella Zoster Virus

3.) Chlamydia

Past Surgical History (PSH):

• Kidney transplant 2008

Sexual/Reproductive History:

Heterosexual

Personal/Social History:

Patient is a tee-tootler and a non-smoker. He also denies abusing any drugs. He enjoys outdoor activities and visiting the countryside. He also engages in swimming from time to time at the local river.

Immunization History:

Covid-19 Vaccine #2 4/8/2021 #2 8/10/2021 AstraZeneca

All his other vaccinations are up to date as per EPI guidelines

Significant Family History:

His parents are both dead due to natural reasons. He has three siblings who are alive. The sister however is diagnosed with asthma. The other two brother experience allergies during specific seasons such as in the spring.

Lifestyle:

The patient is newly married with only a few months having gone by. He is a business man in the import and exports sector. He however has a work- life stable lifestyle and as stated enjoys engaging in outdoor activities. He used to be a professional swimmer however he changed that and swims leisurely for now.

Review of Systems:

General: He denies experiencing any fatigue, loss of appetite or a fever. His complaint is the pain at the site of the rash.

HEENT: He also states he has had any head injury previously thus no visual issues.

He has an excessive wax issue which he has seen an ENT specialist and is managing it. He however has no hearing loss issues, pain or tinnitus. For his nose he reports to nosebleed in extremely cold weather that is associated with the flu he gets in such environments. He denies any soreness of the throat, history of a cough or even a dry mouth.

Neck: There are no pain complaints or discomfort. There are also no distended jugular veins or swollen lymph nodes.

Breasts: There’s no discomfort tenderness nor drainage.

Respiratory: No dyspnea nor shortness of breath neither is there coughing or pain associated.

CV: No reports of dyspnea, palpitations, or chest pain when exerting oneself. Edema, syncope, rheumatic, claudication, or thrombophlebitis histories are not present. Electrocardiograms that were abnormal or negative for hypertension.

GI: Denies experiencing any diarrhea, constipation, diarrhea, nausea, or vomiting. Bowel patterns are normal every three days. No history of dyspepsia, food intolerance, rectal hemorrhage, hemorrhoids, or any of those things.

The patient’s gallbladder has previously been sick.

GU: no hematuria, penile pain or discharge, dysuria, testicular pain, or a history of hernias or UTI. The patient has a history of nocturia, frequent urination, a perception of incomplete bladder emptying, a strong need to urinate, and dribbling after urine. Abnormal patterns of ejaculation. Absence of STD history.

MS: He doesn’t have any complains of muscle or arthritis discomfort. Last year, I slipped and fell in the snow, but I wasn’t hurt or broke. Positive Range of motion in the upper and lower extremities, Trendelenburg gait

PSYCH: Disavows any feelings of sadness, suicidal or homicidal thoughts, anxiety, nightmares, hallucinations, or insomnia. Has a fear of clowns.

NEURO: Negative for headaches, tremors, numbness, weakness, or tingling. There were no vertigo, nausea, blackouts, seizures, or alterations in memory.

INTEGUMENT/HEME/LYMPH: Cluster and scattered rashes on the front and back of the chest. There are no further skin abnormalities.

ENDOCRINE: This region is normal. Currently no hormone therapy.

ALLERGIES/ IMMUNOLOGICAL: No known food or drug allergies and neither environmental nor immunological deficiencies.

OBJECTIVE DATA

PHYSICAL EXAM: B/P 156/90, left arm in a sitting position, regular adult cuff; P 82 and regular; T 98.9 orally; RR 18 and non-labored; PHYSICAL EXAM; Weight: 147 lbs., height: 5’6

General: Well-fed, alert, and talkative. Seems uneasy and is protecting the right upper torso.

HEENT: His head had no visual abnormalities. Neither a history of injuries nor headache symptoms.

Ten years ago, the patient underwent bilateral Lasik surgery, and there was no conjunctivitis. Hearing is not a problem, the ear canal is clear, and the tympanic membranes are pink with obvious land masks. No polyps or post-nasal drip were found. There is no throat inflammation, pain, or redness to speak of. Pink and wet oral mucosa is seen. The size and form of the tonsils are normal.

Lungs and chest: Symmetrical chest. No crackling or wheezing, just clean, equal lung sounds on auscultation throughout the entire lung area. Even and unlabored breathing is being done.

Heart/Peripheral Vascular: Systolic blood pressure in the 150s, slightly raised. Normal heartbeat and rhythm with S1 and S2 sounds absent of gallops or murmurs.

ABD: Abdomen soft, non-tender, and non-dilated with active bowel sounds present in all quadrants.

Genital/Rectal: External circumcision of the genitalia with no sores or scars.

No evidence of a hemorrhage.

Musculoskeletal: AROM to the upper and lower extremities is musculoskeletal. No prior fractures or trauma.

Right hip cannot be totally abducted.

Neuro: Responds to quarry age-appropriately. No unusual sensory or weak points were found.

Skin and lymph nodes: An open, fluid-filled blister is visible on the chest.

ASSESSMENT

LAB TESTS AND RESULTS:

SPO2: 94% with ambient air.

CBC: WBC: 8,000; RBC: 13

Polymerase Chain Reaction (PCR): 243.8

Differential Diagnosis:

Shingles;

Eczema;

Contact Dermatitis

DIAGNOSIS/CLIENT PROBLEM

Because the characteristic rash frequently does not emerge until after the discomfort begins, diagnosing shingles in its early stages can be challenging. Depending on the area of your body that is affected, additional causes such as an appendix infection (appendicitis), a gallbladder infection (cholecystitis), a slipped disk, or even a heart attack, may first be assumed.

Many persons who have shingles initially speculate that they may have an eczematous skin condition that is not communicable. They might believe they don’t need to see a doctor about it as a result, which could delay the diagnosis.

 Primary Diagnoses:

 

1.) Eczema

 

References

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.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th     Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby.      Reprinted by permission of Mosby via the Copyright Clearance Center.

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.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

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.

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

• Median nail dystroph

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

Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.

In this Lab Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.

To Prepare

• Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.
• Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
• Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
• Consider which of the conditions is most likely to be the correct diagnosis, and why.
• Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.
• Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to guide you as you prepare your SOAP note.
• Download the SOAP Template found in this week’s Learning Resources, and use this template to complete this Lab Assignment.

Click here to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS: NURS 6512 Differential Diagnosis for Skin Conditions

The Lab Assignment

• Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
• Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources.

By Day 7 of Week 4

Submit your Lab Assignment.

Submission and Grading Information

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Submit Your Assignment by Day 7 of Week 4

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Week 4 Assignment 1

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 murmur