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Assignment 1: 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 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.
Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this 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.
Download the SOAP Template found in this week’s Learning Resources.
Questions to Answer
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 3 different references from current evidence based literature.
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Learning Resources : Differential Diagnosis for Skin Conditions
Note: To access this week's required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 8, “Skin, Hair, and Nails” (pp. 114-165)
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.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 28, “Rashes and Skin Lesions” (pp. 325-343)
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 Adult Examination Checklist and the Physical Exam Summary when you conduct your video assessment of the skin, hair, and nails.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for skin, hair, and nails. In Mosby's guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Skin, Hair, and Nails was published as a companion to Seidel's guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Skin, hair, and nails physical exam summary. In Mosby's guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Skin, Hair, and Nails Physical Exam Summary was published as a companion to Seidel's guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
Clothier, A. (2014). Assessing and managing skin tears in older people. Nurse Prescribing, 12(6), 278–282. Retrieved from http://www.nurseprescribing.com/
Retrieved from the Walden Library Databases.
Watkins, J. (2013a). Skin rashes, part 1: Skin structure and taking a dermatological history. Practice Nursing, 24(1), 30–33. doi:10.12968/pnur.2013.24.1.30
Retrieved from the Walden Library Databases.
Watkins, J. (2013b). Skin rashes, part 2: Distribution and different types of rashes. Practice Nursing, 24(3), 124–127. Retrieved from http://www.practicenursing.com/
Retrieved from the Walden Library Databases.
Watkins, J. (2013c). Skin rashes, part 3: localized rashes. Practice Nursing, 24(5), 235–241. doi:10.12968/pnur.2013.24.5.235
Retrieved from the Walden Library Databases.
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Skin Condition Number 2
Patient Initials: EG Age: 69 Gender: F
Chief Complaint (CC): Small reddish growths on the skin.
History of Present Illness (HPI): Erica Georges is a 60-year-old African American woman with complaints of lesions that have appeared on her torso. She has had them for the past week, and they have suddenly developed. The growths are raised off the skin with the presence of red blood cells, which is responsible for the reddish appearance. The patient notes that the growths are not itchy nor painful, but the reddish looks scare her, hence the reason she has resorted to seeking medical attention. She has been using hydrocortisone ointment for the past three days without any significant change. The patient reports occasional headaches, dizziness, and insomnia, which are related to other medical conditions, which is hypertension. She is currently taking medicine for hypertension.
Hydrocortisone 3x daily
Bisoprolol 2.5mg tab 1x daily
Past Medical History (PMH):
Apart from the skin rash, the patient reports being in her usual state of health apart from the mild complications related to age and the hypertensive condition. She was diagnosed with hypertension five years ago and has been taking prescription medicine to manage the disease. She adheres to her medication schedule.
Past Surgical History (PSH):
Hip replacement surgery 2001
Personal Social History:
Used to drink alcohol occasionally while on social occasions but stopped ten years ago. No history of illicit drug use. Has never smoked.
Up to date with immunization. Influenza vaccine last November and Pneumococcal 2 years ago
Significant family history:
Has a brother who had eczema since childhood. Has a sister 50 years old who was diagnosed with diabetes two years ago. The mother died of hypertension-related complications, was diagnosed at age 40 and died at age 78. Father diagnosed with diabetes at age 46.
The patient is retired and lives with a 21-year-old granddaughter who works and studies at the same time; hence she is alone in the house most of the time. The husband is deceased, and children have families and live some distance from her home. She does gardening when she has strength. No safety issues reported. No recent travel. She has a homecare nurse who comes twice a week to check her vital signs to ensure that her high blood pressure is not out of control.
She does not observe a nutritional diet. She is overweight and recognizes that this put her at risk of developing several health complications including diabetes. There is a community center nearby that have resources for the elderly. She has insurance, which caters for her prescription medication and other health costs.
Review of Systems:
General: the patient denies any recent fever or body changes. She, however, reports occasional difficulty in sleeping
HEENT: No rash noted near the eyes. No history of eye problem. No reported ear infections. No discharge observed in the ear. No complaints of mouth pain, no sore throat issues, absence of any mucosa swelling. Patient denies nasal stuffiness, no recent history of sinus infection.
Neck: No injury, pain, or history of compression
Breasts: The patient reports no current abnormal mammograms, no report of changes in the breasts.
Respiratory: The patient reports no night sweats, coughs, or dyspenia
Cardiovascular/Peripheral Vascular: No reported chest discomfort, palpitations or history of murmur, no chest pains, denies edema
Gastrointestinal: The patient denies any nausea or vomiting, absence of abdominal pain, no changes in bladder pattern.
Genitourinary: The patient is heterosexual, no change in urinary tract pattern, no history of STD or HPV, the patient is currently not sexually active.
Musculoskeletal: The patient reports no joint inflammation or pain. No history of fractures
Psychiatric: No history of mental illness, suicidal history, or anxiety/depression issues, present occasional sleep disturbance but denies experience of any delusions.
Neurological: No issues with memory or change in thinking patterns, no dizziness, but occasional headaches
Integumentary/Heme/Lymph: Presence of rashes, but do not itch, no bruising, no history of transfusions, no history of skin cancer
Endocrine: No hormone therapies or presence of endocrine issues
Allergic/Immunologic: Has hx of allergy to Isosorbide mononitrate.
Vital signs: BP -137/72 and regular, BMI 33.9, Weight 106.kg (16st 11IB), Height 1.72 (5’8)
General: A&O x3, NAD, comfortable, neatly dressed, alert and conscious
HEENT: PERRLA, EOMI, oronasopharynx is clear, pupils reactive to light and equal
Neck: trachea midline
Chest/Lungs: lungs clear on auscultation, regular respirations
Heart: RRR without murmur, rub, or gallop; pulses+2 bilat pedal
Peripheral Vascular: Abdomen: Not assessed
Genital/Rectal: Absence of cervical motion tenderness, external genitalia intact
Musculoskeletal: Age-related atrophy, normal muscle movement,
Neurological: CN II-XII grossly intact, DTR’s intact
Skin: Reddish lesions raised off the skin surface on the trunk of the body. In other parts of the body, the skin has no palpable nodes, no presence of edema.
Lab Results: Blood test for antinuclear antibody
Presence of lupus
CBC – WBC 7,500 cells/mcL
Hemoglobin 12.6 grams/dL
Lab: positive outcomes with biopsy
Skin biopsy : punch biopsy analyzed under a microscope
sharply bounded vascular proliferation
adnexal structures and collarette of the epithelium
Also known as the Campbell De Morgan spots are cherry red bumps that occur on the skin. They occur either as a single spot on the skin or a group of spots. Most common spot for occurrence is the trunk of the body and the arm. However, they can also occur in other parts of the body; for instance, in rare cases, they occur on the scalp (Kim, Park, & Ahn, 2009). The exact reason why they occur is not known, but they commonly manifest in people from age 30 years onwards. They could be due to broken blood vessels, which bleed under the skin causing the red spots. Other associated causes of cherry angiomas include allergic reactions, aging skin, sun damage, bruise, or certain drugs (Dains, Baumann, & Scheibel, 2016). The aging factor may be the best explanation to account for the occurrence of cherry angiomas since they tend to increase in number as one becomes old. In this diagnosis, age could be the likely cause of cherry angiomas in the patient. The red spots, unlike most skin rashes, are not itchy and even though they appear as though they can burst any time, the spots do not bleed (Watkins, 2013). In addition, they are not dangerous and thus, it is not a necessity to treat them. However, they can be removed using electrocautery, shaving, or using lasers.
Normally, the condition is diagnosed clinically, but for doubts, it can be confirmed using skin biopsy. In this case, scanning the punch of spot reveals a sharply bounded vascular proliferation. In addition, it is characterized by adnexal structures and collarette of the epithelium. It is also important to note that the skin benign changes or growths that occur in the case of cherry angioma do not have cancer cells.
Diagnosis /Client problem
Differential diagnoses (DDx):
Angiokeratoma of the Scrotum
Dains, J. E., Baumann, L., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care. St. Louis, MO: Elsevier Mosby.
Kim, J.-H., Park, H.-y., & Ahn, S. (2009). Cherry Angiomas on the Scalp. Case Rep Dermatol, 1(1): 82–86.
Watkins, J. (2013). Skin rashes, part 2: Distribution and different types of rashes. Practice Nursing, 24(3):124–127. Retrieved from http://www.practicenursing.com/.