The Differential Diagnosis For Skin Conditions Discussion

The Differential Diagnosis For Skin Conditions Discussion

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. The Differential Diagnosis For Skin Conditions Discussion

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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. The Differential Diagnosis For Skin Conditions Discussion
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

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 The Differential Diagnosis For Skin Conditions Discussion.

 

Chapter 9, “Skin, Hair, and Nails”

This chapter reviews the basic anatomy and physiology of skin, hair, and nails. The chapter also describes guidelines for proper skin, hair, and nails assessments.
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.

Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.

This section explains the procedural knowledge needed prior to performing various dermatological procedures.

Chapter 1, “Punch Biopsy”

Chapter 2, “Skin Biopsy”

Chapter 10, “Nail Removal”

Chapter 15, “Skin Lesion Removals: Keloids, Moles, Corns, Calluses”

Chapter 16, “Skin Tag (Acrochordon) Removal”

Chapter 22, “Suture Insertion”

Chapter 24, “Suture Removal”

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 The Differential Diagnosis For Skin Conditions Discussion.

Chapter 28, “Rashes and Skin Lesions”

This chapter explains the steps in an initial examination of someone with dermatological problems, including the type of information that needs to be gathered and assessed.

Note: Download and use the Student Checklist and the Key Points when you conduct your assessment of the skin, hair, and nails in this Week’s Lab Assignment.

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

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

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.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

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

Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Weeks 1 and 3) The Differential Diagnosis For Skin Conditions Discussion
VisualDx. (2021). Clinical decision support: For professionals. Retrieved July 16, 2021, from http://www.skinsight.com/professionals

This interactive website allows you to explore skin conditions according to age, gender, and area of the body.

Bonifant, H., & Holloway, S. (2019). A review of the effects of ageing on skin integrity and wound healing. British Journal of Community Nursing, 24(Sup3), S28–S33. https://doi.org/10.12968/bjcn.2019.24.sup3.s28

Document: Skin Conditions (Word document)

This document contains images of different skin conditions. You will use this information in this week’s Discussion.

Document: Comprehensive SOAP Exemplar (Word document)

Document: Comprehensive SOAP Template (Word document)

The Differential Diagnosis For Skin Conditions Discussion

Differential Diagnosis for Skin Conditions

Patient Initials: O.C.       Age:  41      Gender: Male

SUBJECTIVE DATA:

Skin Condition #5

Chief Complaint: “I have a dry rash, which is peeling, itching, and it is worsening.”

 History of Present Illness (HPI):

Mr O. C. is a 41yo male who reports flaky, scaly, and patchy skin in his upper body parts, particularly his neck and chest. The client discloses experiencing these symptoms for the past 2-3 weeks. He adds that symptoms worsen over time. The client denies changing products applied to the skin. The client denies any pain but reports discomfort. O. C reports applying Aveeno cream on his skin relieves dryness and itching. The cream also relieves discomfort temporarily The Differential Diagnosis For Skin Conditions Discussion.

Medications:

• Aveeno cream is applied on the dry skin to relieve dryness, itching, and discomfort.
• Aspirin 81 mg P.O taken once daily.

Allergies:

Penicillin allergy diagnosed during childhood

Past Medical History (PMH):

No past medical condition

Past Surgical History (PSH): 

Tonsillectomy

Sexual/Reproductive History:

No information provided

Personal/Social History:

The client denies tobacco use. He is a social drinker and only takes alcohol upon going out with friends. He reports being married to one partner.

Immunization History:

He reveals all his immunizations are up to date. The client reports receiving the flu vaccine and pneumonia immunization in 2017 and 2011, respectively.

Significant Family History:

The client reports that his father is an alcoholic and was diagnosed with D.M. type 2. His mother has high blood pressure The Differential Diagnosis For Skin Conditions Discussion.

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Lifestyle: 

He was working in a manufacturing plant before being fired.

Diet:  Denies changes in appetite.

ROS

General: Denies weight gain.

HEENT:  The client denies scars on the head, vision change, hearing difficulties, nasal congestion, swallowing difficulties, or pain in the neck.

Neck:  The client reveals dry and scaly skin, which is covered with silvery scales.

Respiratory:  Denies cough.

Cardiovascular/Peripheral Vascular:  Denies chest pain.

Gastrointestinal: Reports experiencing indigestion and reflux occasionally.

Genitourinary: Denies incontinence.

Musculoskeletal:  Denies swollen joints.

Psychiatric:  Reports anxiety, distress, and insomnia.

Neurological:  Denies dizziness.

Skin: Reports scaly, dry, and patchy white lesions, which have surrounded the neck and torso region. The client further discloses four bumps on his back. Denies scaly and dry skin in other parts of the body.

Hematologic:  Denies bleeding.

Endocrine:  Denies heat or cold intolerance

Allergic/Immunologic: Reports experiencing allergies occasionally.

OBJECTIVE DATA:

Physical Exam:

Vital signs:  B/P 114/71; P 70; T 98.0; RR 12; Wt: 207 lbs; Ht: 5’10”; BMI 24.5.

General: The client is a 43yo male who presented to the clinic with flaky, scaly, and patchy skin in his upper body parts, particularly his neck and chest. He is well-nourished and groomed. He is alert and oriented to places, people, events, and situations. He is attentive and maintains eye contact throughout the clinical interview. His judgment is good, and he seems to be future-oriented. He appears to be in mild distress and anxious The Differential Diagnosis For Skin Conditions Discussion.

HEENT: No head injuries, pupils not dilated, clear canals in both ears, no nasal drainage, and no swelling in the throat.

Neck: Flaky, scaly, and patchy white skin on the neck.

Chest: Symmetric chest movement.

Lungs: No wheezing sound.

Heart: No murmurs.

Peripheral Vascular: No discolouration seen on the lower extremities

Genital/Rectal: No blood spots in the urine or stool.

Musculoskeletal: Depicts normal motor strength

Neurological: He seems to be in mild distress and anxious. He reports insomnia.

Skin: Flaky, patchy, and scaly lesions in areas surrounding his neck and chest and some bumps in the back region.

ASSESSMENT:

1. Psoriasis – Primary diagnosis
2. Eczema
3. Subacute Cutaneous Lupus Erythematosus (SCLE)
4. Pityriasis Rosea

The primary diagnosis for this client is psoriasis. According to Agozzino et al. (2017), psoriasis is characterized by various clinical manifestations, including red and small bumps filled with pus. These bumps cause scaly, dry, and itchy patches covered with silvery scales. The client reports flaky, patchy, dry, and scaly lesions around his chest and neck. Therefore, psoriasis qualifies as the client’s primary diagnosis. The second potential diagnosis for this client is eczema. This skin condition is mainly characterized by dry and itching skin. In most cases, these symptoms become severe at night. The client reports itching and dry skin, making Eczema a potential diagnosis. SCLE is another potential diagnosis for this client. This skin condition is characterized by rashes that may appear on the back, arms, neck, or chest (Nutan & Ortega-Loayza, 2017). The client has reported rashes surrounding his neck and chest, making SCLE a potential diagnosis. Lastly, the client can be diagnosed with Pityriasis Rosea. According to Villalon-Gomez (2018), people with this skin condition report scaly spots in various body parts, particularly the chest, back, or abdomen. These spots then spread to form an itching patch that worsens over time. The client reports itching, dry, and scaly rashes surrounding the neck and chest. For this reason, Pityriasis Rosea qualifies as a potential diagnosis for this client The Differential Diagnosis For Skin Conditions Discussion.

References

Agozzino, M., Noal, C., Lacarrubba, F., & Ardigò, M. (2017). Monitoring treatment response in Psoriasis: current perspectives on the clinical utility of reflectance confocal microscopy. Psoriasis; 7:27-34.

Nutan, F & Ortega-Loayza, A, G. (2017). Cutaneous Lupus: A Brief Review of Old and New Medical Therapeutic Options. J Investig Dermatol Symp Proc; 18(2):S64-S68

Villalon-Gomez, J. M. (2018). Pityriasis rosea: diagnosis and treatment. American family physician, 97(1), 38-44.

Comprehensive SOAP Exemplar

 Purpose: To demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.

Patient Initials: _______                 Age: _______                                   Gender: _______

SUBJECTIVE DATA:

Chief Complaint (CC): Coughing up phlegm and fever

History of Present Illness (HPI): Eddie Myers is a 58 year old African American male who presents today with a productive cough x 3 days, fever, muscle aches, loss of taste and smell for the last three days. He reported that the “cold feels like it is descending into his chest and he can’t eat much”. The cough is nagging and productive. He brought in a few paper towels with expectorated phlegm – yellow/green in color. He has associated symptoms of dyspnea of exertion and fatigue. His Tmax was reported to be 100.3, last night. He has been taking Tylenol 325mg about every 6 hours and the fever breaks, but returns after the medication wears off. He rated the severity of her symptom discomfort at 8/10.

Medications:

• Norvasc 10mg daily
• Combivent 2 puffs every 6 hours as needed
• Advair 500/50 daily
• Singulair 10mg daily
• Over the counter Tylenol 325mg as needed
• Over the counter Benefiber
• Flonase 1 spray each night as needed for allergic rhinitis symptoms The Differential Diagnosis For Skin Conditions Discussion

Allergies:

Sulfa drugs – rash

Cipro-headache

 Past Medical History (PMH):

1.) Asthma

2.) Hypertension

3.) Osteopenia

4.) Allergic rhinitis

5.) Prostate Cancer

Past Surgical History (PSH):

• Cholecystectomy 1994
• Prostatectomy 1986

Sexual/Reproductive History:

Heterosexual

Personal/Social History:

He has never smoked

Dipped tobacco for 25 years, no longer dipping

Denied ETOH or illicit drug use.

Immunization History:

Covid Vaccine #1 3/2/2021 #2 4/2/2021 Moderna

Influenza Vaccination 10/3/2020

PNV 9/18/2018

Tdap 8/22/2017

Shingles 3/22/2016

 Significant Family History:

One sister – with diabetes, dx at age 65

One brother–with prostate CA, dx at age 62. He has 2 daughters, both in 30’s, healthy, living in nearby neighborhood.

 Lifestyle:

He works FT as Xray Tech; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. He is a college grad, owns his home and financially stable.

He has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. He has medical insurance but often asks for drug samples for cost savings. He has a healthy diet and eating pattern. There are resources and community groups in his area at the senior center but he does not attend. He enjoys golf and walking. He has a good support system composed of family and friends.

 Review of Systems:

General: + fatigue since the illness started; + fever, no chills or night sweats; no recent weight gains of losses of significance.

HEENT: no changes in vision or hearing; he does wear glasses and his last eye exam was 6 months ago. He reported no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. He does have bilateral small cataracts that are being followed by his ophthalmologist. He has had no recent ear infections, tinnitus, or discharge from the ears. He reported no sense of smell. He has not had any episodes of epistaxis. He does not have a history of nasal polyps or recent sinus infection. He has history of allergic rhinitis that is seasonal. His last dental exam was 1/2020. He denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. He has had no difficulty chewing or swallowing.

Neck: Denies pain, injury, or history of disc disease or compression..

Breasts:. Denies history of lesions, masses or rashes.

Respiratory: + cough and sputum production; denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; he has history of asthma and community acquired pneumonia 2015. Last PPD was 2015. Last CXR – 1 month ago.

CV: denies chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. Date of last ECG/cardiac work up is unknown by patient.

GI: denies nausea or vomiting, reflux controlled, Denies abd pain, no changes in bowel/bladder pattern. He uses fiber as a daily laxative to prevent constipation.

GU: denies change in her urinary pattern, dysuria, or incontinence. He is heterosexual. No denies history of STD’s or HPV. He is sexually active with his long time girlfriend of 4 years.

MS: he denies arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. denies history of trauma or fractures.

Psych: denies history of anxiety or depression. No sleep disturbance, delusions or mental health history. He denied suicidal/homicidal history.

Neuro: denies syncopal episodes or dizziness, no paresthesia, head aches. denies change in memory or thinking patterns; no twitches or abnormal movements; denies history of gait disturbance or problems with coordination. denies falls or seizure history.

Integument/Heme/Lymph: denies rashes, itching, or bruising. She uses lotion to prevent dry skin. He denies history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties or history of transfusions.

Endocrine: He denies polyuria/polyphagia/polydipsia. Denies fatigue, heat or cold intolerances, shedding of hair, unintentional weight gain or weight loss.

Allergic/Immunologic: He has hx of allergic rhinitis, but no known immune deficiencies. His last HIV test was 2 years ago. The Differential Diagnosis For Skin Conditions Discussion

OBJECTIVE DATA

 Physical Exam:

Vital signs: B/P 144/98, left arm, sitting, regular cuff; P 90 and regular; T 99.9 Orally; RR 16; non-labored; Wt: 221 lbs; Ht: 5’5; BMI 36.78

General: A&O x3, NAD, appears mildly uncomfortable

HEENT: PERRLA, EOMI, oronasopharynx is clear

Neck: Carotids no bruit, jvd or thyromegally

Chest/Lungs: Lungs pos wheezing, pos for scattered rhonchi

Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial

ABD:  nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound

Genital/Rectal: pt declined for this exam

Musculoskeletal: symmetric muscle development – some age related atrophy; muscle strengths 5/5 all groups.

Neuro: CN II – XII grossly intact, DTR’s intact

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

Diagnostics/Lab Tests and Results:

CBC – WBC 15,000 with + left shift

SAO2 – 98%

Covid PCR-neg

Influenza- neg

Radiology:

CXR – cardiomegaly with air trapping and increased AP diameter

ECG

Normal sinus rhythm

Spirometry- FEV1 65%

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 Assessment:

 Differential Diagnosis (DDx):

• Asthmatic exacerbation, moderate
• Pulmonary Embolism
• Lung Cancer

 Primary Diagnoses:

 1.) Asthmatic Exacerbation, moderate

 PLAN: [This section is not required for the assignments in this course, but will be required for future courses.] The Differential Diagnosis For Skin Conditions Discussion