Feb 23, 2024 NURA 6512 Assignment Differential Diagnosis for Skin Conditions
NURA 6512 Assignment Differential Diagnosis for Skin Conditions
NURA 6512 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.
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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
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.
NURA 6512 Assignment Differential Diagnosis for Skin Conditions
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):
Tonsilitis
Appendicitis
Past Surgical History (PSH):
Tonsillectomy
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
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.
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.
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.
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 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
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.
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.
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