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Differential Diagnosis for Skin Conditions 

Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions
 
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. (for example :  Small, itch, raised patches on lower back or any other skin condition)

•    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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Please use Below template for the Soap note
The Soap Note 
SOAP acronym = Subjective, Objective, Assessment and Plan  
•    Subjective - What the patient says about the problem / intervention. 
•    Objective - The objective observations and treatment interventions  
•    Assessment - The analysis of the various components of the assessment. 
•    Plan - How the treatment will be developed to the reach the goals or objectives.
The “S” Subjective ?Includes:
  Subjective Data 
1-    Past medical history (PMH) Past surgical history (PSH) Social history (SH)
Family history (FH) 
2-    Current medication (include prescribed and over the counter) Allergies (medications and food – include reaction) 
3-    Sexual history – (five P’s: partners, practices, protection from STDs, past history of STDs, and prevention of pregnancy) 
4-    OB/GYN – (LMP, hx of pregnancy, abortion) 
5-    Review of Systems

Review of Systems 
1-    Captures an overall snapshot of the patient Include pertinent positives and negatives 
2-    What should you ask?
- Annual physical exam – a full review of systems (head to toe)
- Episodic – focus on systems that is related to the chief complaint and HPI ? --- Follow up visit – focus on systems related to the follow up visit

Review of Systems 
(These are always questions to your patients. The patient will denied or agree about the presence of the symptom)
Constitutional/General: fevers, chills, unintentional weight loss, fatigue, pain, night sweats 
Skin – excessive dryness, rash or lesions (do you have or had any …..)
HEENT – headaches, visual disturbances, excessive tearing, eye redness, dryness; ear pain, hearing changes, (nose) nasal congestion or rhinitis, sinus fullness; sore throat, hoarseness, dry mouth 
Neck – pain or stiffness; swollen lymph nodes, lumps
Breasts: lumps, discomfort, nipple discharge, self?exam practices
Resp – SOB, DOE, cough (quality), wheezing
CV – chest pain/discomfort; palpitations, orthopnea, peripheral edema (swelling of hands and/or feet)
GI – abdominal pain/discomfort, nausea, vomiting, acid reflux, trouble swallowing, changes in bowel
GU – urinary frequency, nocturia, dysuria (females – vaginal discharge, dyspareunia, prolonged menses; males – urinary stream) MSK – joint pain or stiffness, swelling, redness; muscle aches; weakness
Neuro – headaches, dizziness, numbness, tingling, tremors, gait problems
Psych – memory changes, mood changes, sleep disturbance, anxiety, depressive symptoms, suicidal ideation
Endocrine: heat or cold intolerance; excessive sweating; excessive thirst, hunger or urination;
Heme: Easy bruising, bleeding gums, history of transfusion 
Objective Data 
Vital signs – blood pressure, heart rate, respiratory rate, temperature, O2 saturation Arthrometric data – Ht, wt, BMI
Point of care (POC) blood sugars, A1c, rapid strep, urinalysis
Physical exam 
Diagnostic testing results (recent imaging, labs) 
Physical Exam 
(Is actually a physical finding during your actual examination, manipulating, percussing, palpating or auscultating the patient)
o    Constitutional: Well groomed, well developed male/female, sitting on exam table, no apparent distressed; appears stated age 
o    Skin: Warm and dry. No lesions, tattoos, or scars noted 
o    HEENT: Head normocephalic, atraumatic; bilateral eyes anicteric, PERRL; bil inner ears without erythema or exudate. Bilateral ear drums translucent and in neutral position. Nasal passages patent bilateral, no exudate noted. Oropharynx moist, pink without exudate, tonsils present 2+ bilateral, no exudate or lesions noted. No dental caries or missing teeth noted. 
o    Neck: supple, thyroid smooth, no palpable nodules or lymphadenopathy 
o    Breasts: note size and contour, Inspect for symmetry, dimpling, nipple (inverted?), axillary nodes; gynecomastia in males. 
o    CV: Heart rate regular rhythm (HRRR), S1S2 distinct, no extra beat, murmurs or gallops; no lower extremity edema. 2+DP pulse bilateral 
o    Resp: Lungs clear to auscultation (CTA) bilateral; no adventitious sounds 
o    GI: Abdomen soft (flat, round, or obese), bowel sounds presents in all 4 quadrants; no palpable masses or tenderness 
o    GU: Female/Male–inspect for lesions, nits,(male scrotum, penis, circumcised or uncircumcised; female labial folds, vaginal walls, cervix for color, size, discharge, lesions, bleeding, atrophy, tenderness, etc.) 
o    MSK: Joints without obvious deformities; all extremities with full range of motion (FROM); muscle strength 5/5 upper and lower and lower extremity; gait smooth and steady; 
o    Neuro: Cranial nerves II–Xll grossly intact, no focal deficit 
o    Psych: Good eye contact; speech and affect appropriateeAssessment:  The assessment section is where you write your thoughts on the salient issues and the diagnosis (or differential diagnosis), which will be based on the information collected in the previous two sections.
  The “A” in Assessment (diagnosis)
  Descriptors + factual = interpretation ? Assessment for each problem
   
Summarize the salient points:
•    Productive cough (green sputum)
•    Increasing shortness of breath
•    Tachypnea (respiratory rate 22) and hypoxia (O2 saturations 87% on air)
•    Right basal crackles on auscultation
•    Bloods – Raised white cell count (15) / Raised CRP (80)
•    Chest x-ray – increased opacity in the right lower zone in keeping with consolidation   
Document your impression of the diagnosis (or differential diagnosis):
•    Impression – Community acquired pneumonia
 
If the diagnosis is already known and the findings of your assessment remain in keeping with that diagnosis, you can comment on whether the patient is clinically improving or deteriorating:
•    On day 3 of treatment for community acquired pneumonia
•    Reduced shortness of breath and improved cough
•    Oxygen saturations 98% on air / Respiratory rate 15
•    Bloods – CRP decreasing (20) / White cell count decreasing (11)
Impression – Resolving community acquired pneumonia
Plan
The final section is the plan, which is where you document how you are going to address or further investigate any issues raised during the review. 
Things to consider including in your plan:
•    Further investigations – laboratory tests/imaging
•    Treatments – medications/IV fluids/oxygen/nutrition
•    Referrals to various specialties
•    Review date/time – “I will review at 4pm this afternoon”
•    Frequency of observations/monitoring of fluid balance
•    Planned discharge date if relevant
•    The general survey includes the patient\'s weight, height, body build, posture, gait, obvious signs of distress, level of hygiene and grooming, skin integrity, vital signs, oxygen saturation, and the patient\'s actual age compared and contrasted to the age that the patient actually appears like

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Differential Diagnosis for Skin Conditions

Subjective:

CC: “I have ugly bumps on my face since I turned fourteen.”

HPI: Mrs. X is a 24 years old American female complaining of a rash and break-outs after turning fourteen. Her face feels greasy and she often feels a need to squeeze out pus from the lesions. The break-outs are worse during her periods and she has used several over the counter topical products over the years.

Current medications: She is not taking any oral medications.

PMH: She has no history of hospitalization and no known food or drug allergies.

Past Surgical History (PSH): She has no history of surgical intervention.

Reproductive History: She has a regular menstrual cycle after every 28 days lasting 5 days. She does not use any contraceptives but regularly engages in unprotected sex with her three boyfriends. She is a mother of one child from a past relationship and denies any possibility that she could be pregnant. She is currently on her third day of menstruation.

Social history: She smokes one to two cigarettes a week when she feels ugly due to the lesions. She does not use alcohol or any other illicit drugs. She works as a hairdresser 6 hours every day apart from weekends and eats fast foods due to the time-constraints of the job.

Family History: Her mother also had the same skin presentations when she was young.

 

 

ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclera. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: Skin-breaks on the face, chest, and back.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: No burning on urination, urgency, hesitancy, odor, or odd color.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

Examination: Erythematous papules, few pustules, open and closed comedones at the forehead, check, and chin. There are large nodules on the jaw line and erythematous papules on her back and chest. There is no background erythema or scaling.

Mrs. X weighs 180 pounds with a height of 5 feet 3 inches (BMI: 31.9).

Vital signs: Blood pressure-128/70 mmHg, Pulse- 84 b/m, Respirations- 16 b/m, Temperature- 96 degrees Fahrenheit, Oxygen saturation 97% on RA.

Diagnostic Test: Nucleic acid amplification test- Chlamydia and gonorrhea have a high infection rate among women aged 20 to 25 (CDC, 2014). The patient engages in sexual relationships with multiple partners, a sign of irresponsible sexual behaviour. It is a necessary test for comprehensive care.

Results: Negative for gonorrhea and chlamydia.

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Assessment:

Differential Diagnosis:

Mrs. X presents with 3 types of primary lesions, pustules, and comedones. She has folliculopapular eruptions on her chest, face, and upper back consistent with a diagnosis of Acne Vulgaris. Also, occurrence is prevalent among adolescents (80% of teenagers) and it may persist beyond the age of 25 years (Purdy & De Berker, 2011). Risk factors include a positive family history, smoking, excessive dietary fat, psychological stress, and excessive consumption of carbonated drinks (Al Hussein et al., 2018). The patient reports initial manifestations during her adolescence, has a positive family history of the skin eruptions, she is a smoker, and has an unhealthy diet enough to increase her risk for acne vulgaris. Additionally, acne follows a chronic cause with intermittent flares and Mrs. X has had intermittent flares for the past several years.

Rosacea is a differential diagnosis for the patient due to its folliculopapular manifestation. It is also chronic in nature and common in women with a lighter skin. The classical symptoms are a small, reddish, pus-filled pimples during a flare-up (Del Rosso et al., 2019). However, all forms of rosacea affect the face which does not explain the papules on the patient’s upper back and chest. Moreover, the skin papules lack background erythema and telangiectasias.

Perioral dermatitis is also a differential diagnosis for Mrs. X. It is an inflammatory rash that affects the skin around the mouth and may spread to the nose and eyes. It is common among women aged 16 to 45 years but occurs in all ages and races (Tolaymat & Hall, 2020). Symptoms may disappear but then re-occur after some months. Mrs. X presents with a mixture of papules, nodules, and comedones with a diffuse presentation. It is more likely a presentation of acne vulgaris than perioral dermatitis.

Plan:

  • The patient was treated with topical retinoid, benzoyl peroxide and doxycycline 100 mg twice daily. They are effective in reducing inflammatory and non-inflammatory lesions by direct inhibition of sebum production and comedolysis (Oge et al., 2019). Systemic antibiotics are used in moderate to severe cases of acne vulgaris to prevent resistance and enhance effectiveness of the topical options.

  • Advised on proper diet to include low-glycemic products, weekly intake of fish, vegetables, and fruits (Al Hussein et al., 2016).

  • The patient reassured and referred for psychological review. Assurance and counselling is important to reduce disease-related psychosocial sequelae (Revol et al., 2015).

  • Patient given a return date after 8 weeks. Therapeutic interventions for acne vulgaris requires a minimum of eight weeks before assessing for effectiveness unless there are intolerable side-effects/adverse reactions.

 

 

 

 

 

References

Al Hussein, S. M., Al Hussein, H., Vari, C. E., Todoran, N., Al Hussein, H., Ciurba, A., & Dogaru, M. T. (2016). Diet, Smoking and Family History as Potential Risk Factors in Acne Vulgaris-a Community-Based Study. Acta Medica Marisiensis, 62(2).

Centers for Disease Control and Prevention. Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae—2014. MMWR Recomm Rep. 2014; 63:1-19.

Del Rosso, J. Q., Tanghetti, E., Webster, G., Gold, L. S., Thiboutot, D., & Gallo, R. L. (2019). Update on the management of rosacea from the American Acne & Rosacea Society (AARS). The Journal of clinical and aesthetic dermatology, 12(6), 17.

Ogé, L. K., Broussard, A., & Marshall, M. D. (2019). Acne vulgaris: diagnosis and treatment. American family physician, 100(8), 475-484.

Purdy, S., & de Berker, D. (2011). Acne vulgaris. BMJ clinical evidence, 2011. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3275168/

Revol, O., Milliez, N., & Gerard, D. (2015). Psychological impact of acne on 21st‐century adolescents: decoding for better care. British Journal of Dermatology, 172, 52-58. https://doi.org/10.1111/bjd.13749

Tolaymat, L., & Hall, M. R. (2020). Perioral dermatitis. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK525968/

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