Feb 23, 2024 Lab Assignment: Differential Diagnosis for Skin Conditions NURS 6512
Lab Assignment: Differential Diagnosis for Skin Conditions NURS 6512
Lab Assignment Differential Diagnosis for Skin Conditions NURS 6512
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.
Lab Assignment Differential Diagnosis for Skin Conditions NURS 6512
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.
Lab Assignment: Differential Diagnosis for Skin Conditions NURS 6512
Photo Credit: Getty Images/iStockphoto
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 differential diagnosis techniques 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 examine for this Lab Assignment closely.
Also Read: Assignment 2: Digital Clinical Experience (DCE): Health History Assessment NURS 6512N-32
Lab Assignment: Differential Diagnosis for Skin Conditions NURS 6512
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 cause skin abnormalities in your selected graphics.
Consider which conditions are 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 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
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Instead of the traditional narrative style, choose one skin condition graphic (identity by number in your Chief Complaint) to document your Assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format. For more information, see Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources. Remember that not all comprehensive SOAP data is included in each patient case.
Explain the physical characteristics depicted in the graphic using clinical terminology. Create a differential diagnosis of three to five conditions for your selected skin graphic. Determine which diagnosis is most likely correct and explain your reasoning using at least three references, one from current evidence-based literature from your search and two from this week’s Learning Resources.
By Day 7 of Week 4
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Week 4 Assignment 1 Rubric
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To check your Assignment draft for authenticity:
Submit your Week 4 Assignment 1 draft and review the originality report.
Submit Your Assignment by Day 7 of Week 4
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Week 4 Assignment 1
Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions
Patient Information: R.S, a 50-year-old male
Subjective
CC: Nasal congestion as well as itching for the last five days
HPI: R.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 five 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, one tab orally daily.
Allergies: The patient denied any history of drug or food allergies. The patient reported a history of seasonal allergies.
PMHx: The patient denied a history of hospitalization, surgery, and blood transfusion. The immunization history of the client is up to date.
Social Hx: The patient is married with two children. The patient stopped smoking in 2012. He drinks alcohol on an occasional basis. His highest level of education is at university. He has a degree in business administration and works at a local supermarket as a manager. He reported engaging in active physical activity. He reported that the symptoms of the disease had affected his sleeping patterns significantly.
Family Hx: The parents of the patient are both alive. His father was diagnosed with diabetes in 2016 and has been in 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.
ROS
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 the absence of ear drainage or 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 the absence of tonsillitis. The throat was mildly erythematous.
Neck: The trachea was midline without any deviation or lymphadenopathy.
Skin: The patient denied skin rash, changes in skin color, and itching.
Cardiovascular: The patient denied chest pain, palpitations, discomfort, or edema.
Respiratory: The patient denied shortness of breath, cough, or difficulty in breathing.
Musculoskeletal: The patient denied joint or muscle pain.
Lymphatic: The client denied lymphadenopathy
Allergies: The client denied any known food or drug allergies. He reported seasonal allergies.
Objective
HEENT: The patient reports that his eyes are itchy. The eyes appear red. The tympanic membranes are intact with the absence of any drainage. The nasals are congested, with boggy, pale mucosa and inflamed nasal turbinates. There is evidence of drainage of thin, clear secretion. There is mild erythema on the throat without tonsillitis and bleeding.
Diagnostic Results
The skin test revealed a positive reaction to pollen. The results showed that the patient has allergic rhinitis. Allergic rhinitis is a condition of the upper respiratory system that arises from a separate exposure to an allergen. Patients experience symptoms that include sneezing, rhinorrhea, itchy nose and eyes, nasal congestion, and sore throat; Diagnostic investigations are not recommended for allergic rhinitis since they do not have any cost benefits. Healthcare providers can utilize history taking and physical examination to diagnose patients with the condition. It is important to perform skin tests to determine whether a patient has allergic rhinitis in people without a history of allergic reactions.
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 nasal congestion, rhinorrhea, sneezing, and itchy eyes. However, patients do not have a 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 a history of seasonal allergies.
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 the least possible condition due to the absence of signs and symptoms associated with infections.
Flu/Common cold: Common cold is the other potential diagnosis. The common cold is an acute viral infection affecting the upper respiratory system. It may involve the sinuses, the larynx, or the pharynx. Patients experience symptoms such as nasal drainage, malaise, fever, and headache. 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 the least suffering from sore throat because of the absence of signs and symptoms of infection (Mahalingam et al., 2020).
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
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