NURS6512 Week 4 Differential Diagnosis for Skin Conditions Assignment

NURS6512 Week 4 Differential Diagnosis for Skin Conditions Assignment

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.

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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 Assignment.

· Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies? NURS6512 Week 4 Differential Diagnosis for Skin Conditions Assignment

· 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.

To complete:

· 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.

Links:

http://www.skinsight.com/professionals

https://www.aafp.org/afp/2010/0315/p726.html

https://www.aafp.org/afp/2010/0315/p735.html

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): Sara Jones is a 65-year-old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last 3 days. She reported that the “cold feels like it is descending into her chest.” The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4 last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but it returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10.

Medications:

1.) Lisinopril 10mg daily

2.) Combivent 2 puffs every 6 hours as needed

3.) Serovent daily

4.) Salmeterol daily

5.) Over-the-counter Ibuprofen 200mg -2 PO as needed

6.) Over-the-counter Benefiber

7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms

Allergies:

Sulfa drugs - rash

Past Medical History (PMH):

1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and hand held nebulizer treatments.

2.) Hypertension – well controlled

3.) Gastroesophageal reflux (GERD) – quiet, on no medication

4.) Osteopenia

5.) Allergic rhinitis

Past Surgical History (PSH):

1.) Cholecystectomy 1994

2.) Total abdominal hysterectomy (TAH) 1998

Sexual/Reproductive History:

Heterosexual

G1P1A0

Non-menstruating – TAH 1998

Personal/Social History:

She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.

Immunization History:

Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.

Significant Family History:

Two brothers – one with diabetes, dx at age 65, and the other with prostate CA, dx at age 62. She has one daughter in her 30s, healthy, living in nearby neighborhood.

Lifestyle:

She is retired, has been widowed x 8 years, and lives in the city in a moderate crime area with good public transportation. She is a college graduate, owns her home, and receives a pension of $50,000 annually – financially stable.

She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center that she attends regularly. She enjoys bingo. She has a good support system composed of family and friends. NURS6512 Week 4 Differential Diagnosis for Skin Conditions Assignment

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; she does wear glasses, and her last eye exam was 1 ½ years ago. She reported no history of glaucoma, diplopia, floaters, excessive tearing, or photophobia. She does have bilateral small cataracts that are being followed by her ophthalmologist. She has had no recent ear infections, tinnitus, or discharge from the ears. She reported her sense of smell is intact. She has not had any episodes of epistaxis. She does not have a history of nasal polyps or recent sinus infection. She has a history of allergic rhinitis that is seasonal. Her last dental exam was 3/2014. She denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. She has had no difficulty chewing or swallowing.

Neck: No pain, injury, or history of disc disease or compression. Her last Bone Mineral density (BMD) test was 2013 and showed mild osteopenia, she said.

Breasts: No reports of breast changes. No history of lesions, masses, or rashes. No history of abnormal mammograms.

Respiratory: + cough and sputum production (see HPI); denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; she has history of COPD and community acquired pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago.

CV: No 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: No nausea or vomiting, reflux controlled. No abd pain, no changes in bowel/bladder pattern. She uses fiber as a daily laxative to prevent constipation.

GU: No change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She has had a total abd hysterectomy. No history of STDs or HPV. She has not been sexually active since the death of her husband.

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

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

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

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

Endocrine: No endocrine symptoms or hormone therapies.

Allergic/Immunologic: Has hx of allergic rhinitis, but no known immune deficiencies. Her last HIV test was 10 years ago.

OBJECTIVE DATA

Physical Exam:

Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 orally; RR 16; non-labored; Wt: 115 lbs; Ht: 5’2; BMI 21

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

HEENT: PERRLA, EOMI, oronasopharynx is clear

Neck: Carotids no bruit, jvd or tmegally

Chest/Lungs: CTA AP&L

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

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

Genital/Rectal: external genitalia intact, no cervical motion tenderness, no adnexal masses.

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

ASSESSMENT:

Lab Tests and Results:

CBC – WBC 15,000 with + left shift

SAO2 – 98%

Diagnostics:

Lab:

Radiology:

CXR – cardiomegaly with air trapping and increased AP diameter

ECG

Normal sinus rhythm

Differential Diagnosis (DDx):

1.) Acute Bronchitis

2.) Pulmonary Embolis

3.) Lung Cancer

Diagnoses/Client Problems: NURS6512 Week 4 Differential Diagnosis for Skin Conditions Assignment

1.) COPD

2.) HTN, controlled

3.) Tobacco abuse – 40-pack-a-year history

4.) Allergy to sulfa drugs – rash

5.) GERD – quiet, on no current medication

PLAN: [This section is not required for the assignments in this course but will be required for future courses.]

ADULT EXAMINATION CHECKLIST

Guide for Skin, Hair, and Nails

Check (✔) if normal, * if abnormal, Ø if absent

Subjective Data

Skin Hair ______ Eruptions ______ Use of dyes, permanents ______ Lesions/sores/rashes ______ Changes in: ______ Color changes ______ Amount ______ Texture changes ______ Texture ______ Bruising ______ Character ______ Infections ______ Hair loss ______ Birthmarks ______ Hair care: ______ Skin growths ______ Shampoo ______ Acne ______ Conditioner ______ Moles ______ Distribution ______ Itching ______ Body hair ______ Masses ______ Hair on head ______ Excessive sweating ______ Shaving ______ Skin care ______ Face

______ Bathing ______ Axillary ______ Soaps ______ Legs ______ Lotions

______ Pigmentation changes or Nails discoloration ______ Changes in appearance

______ Splitting ______ Cracking ______ Peeling ______ Discoloration

______ Texture ______ Nail care

Detail those marked abnormal: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

Objective Data: Inspection and Palpation

Skin Primary Lesions Configuration of Lesions ______ Grouped (clustered) ______ Macule (flat, < 1 cm) ______ Herpetiform (Zosteriform)—nerve ______ Patch (> 1 cm) ______ Linear (line) ______ Papule (palpable, < 1 cm) ______ Annular (circle) ______ Plaque (> 1 cm) ______ Polycyclic (multiple circles) ______ Nodule (solid, raised, deep, 1-2 cm) ______ Arciform (bow-shaped) ______ Tumor (2 cm) ______ Reticular (lesions meshed) ______ Vesicle (fluid-filled, < 1 cm) ______ Confluent (lesions merged) ______ Bulla (> 1 cm) ______ Discrete (individual) ______ Pustule (purulent vesicle/bulla) ______ Iris/target (concentric rings) ______ Wheal (cutaneous edema) ______ Gyrate (spiral) ______ Cyst (encapsulated)

Color of Lesions Secondary Lesions __________________________________ ______ Scale (loose surface epithelium) __________________________________ ______ Crust (dried surface fluids) __________________________________ ______ Excoriation (scratch)

______ Erosion (loss of epidermis) Description of Lesions ______ Scar __________________________________ ______ Ulcer (loss of epidermis, dermis) __________________________________ ______ Atrophy __________________________________ ______ Keloid (enlarged scar)

______ Fissure (crack) Texture and Firmness ______ Lichenification (thickened, with irrita- __________________________________ tion) __________________________________ __________________________________

Distribution __________________________________ __________________________________ __________________________________

Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

Vascular Lesions ______ Purpura (red/purple, > 0.5 cm) ______ Mongolian spots ______ Petechiae (< 0.5 cm) ______ Pattern injuries ______ Ecchymosis (bruise) Location ________________________ ______ Spider angioma ________________________________

(red body, radiating legs) ________________________________ ______ Venous star (blue spider, linear) ________________________________ ______ Telangiectasia ______ Dry skin

(dilated capillaries) Location ________________________ ______ Capillary hemangioma ________________________________

(red, irregular patches) ________________________________ ______ Cherry angioma ________________________________ ______ Strawberry angioma ______ Skin turgor ______ Port-wine stain ______ Tenting

______ < 2 sec Other Skin Lesions ______ 2-3 sec ______ Corn ______ 3-4 sec ______ Callus ______ > 4 sec ______ Cutaneous tag ______ Contact dermatitis

Other Skin Conditions Detail those marked abnormal: ______ Pallor ______________________________________

Location __________________ ______________________________________ __________________________ ______________________________________ __________________________ ______________________________________

______ Erythema ______________________________________ Location __________________ ______________________________________ __________________________ ______________________________________ __________________________ ______________________________________

______ Cyanosis Location __________________ Hair: Inspection and Palpation __________________________ ______ Texture _________________________ __________________________ ______ Color ___________________________

______ Jaundice ______ Distribution ______ Vitiligo Body ___________________________ ______ Location __________________ ________________________________

__________________________ Head ___________________________ __________________________ ________________________________

________________________________ ______ Clean shaven

Thickness _______________________ ________________________________

______ Dryness

Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

______ Inflammation Detail those marked abnormal: ______ Alopecia ______________________________________

____________________________ ______________________________________ ______________________________________

Nails: Inspection and Palpation ______________________________________ ______ Color _______________________ ______________________________________ ______ Length______________________ ______________________________________ ______ Clean ______________________________________ ______ Pigment deposits ______________________________________ ______ Bands ______________________________________ ______ Streaks ______________________________________ ______ Spots ______________________________________ ______ Smooth nail edges ______________________________________ ______ Ridging ______________________________________ ______ Grooves ______________________________________ ______ Pitting ______________________________________ ______ Curved, smooth nail plate ______________________________________ ______ Nail base angle—160 degrees ______________________________________ ______ Adheres to nail bed ______________________________________ ______ Clubbing ______________________________________

Seidel: Mosby’s Guide to Physical Examination, 7 th Edition

Chapter 8 : Skin, Hair, and Nails

RTF-downloadable Physical Exam Summary

This review discusses examination of the skin, hair, and nails.

Before the exam, gather the necessary equipment: a clear, flexible centimeter ruler; flashlight with transilluminator; handheld magnifying glass; and Wood’s lamp.

To examine the skin, perform the following.

Use inspection and palpation to examine the skin. Make sure you have adequate lighting, preferably with daylight.

 

  • Inspect the skin in two ways.
  • First, perform a brief overall visual sweep of the entire skin surface. This helps identify the distribution and extent of any lesions, assess skin symmetry, detect differences between body areas, and compare sun-exposed areas to areas that were not exposed to the sun.
  • Second, observe the skin as each part of the body is examined.
  • During inspection, expose the skin completely. As you finish inspecting each area, remember to redrape or cover the patient for warmth and modesty.

 

When evaluating the skin (and mucous membranes) in each part of the body, note six characteristics.

 

  • The first characteristic is color, which can vary from dark brown to light tan with pink or yellow overtones.
  • The second characteristic is uniformity. The skin should be uniform in color overall with no localized areas of discoloration. However, the skin may have sun-darkened areas as well as darker skin around the knees and elbows.
  • The third characteristic is thickness, which varies over the body. The thinnest skin is on the eyelids. The thickest is in areas of pressure or rubbing, such as the soles and palms.
  • The fourth characteristic is symmetry. Normally, the skin appears bilaterally symmetrical.
  • The fifth characteristic is hygiene, which may contribute to skin condition.
  • The final characteristic is the presence of any lesions, which are any pathologic skin change or occurrence.
  • During inspection, also palpate the skin to determine five characteristics.
  • First, palpate to detect moisture. Minimal perspiration or oiliness should be present. Even intertriginous areas should display little dampness.
  • Second, use the dorsal surface of your hands to assess temperature. The skin may feel cool to warm, but should be bilaterally symmetrical.
  • Third, check the texture, which should be smooth, soft, and even. However, roughness on exposed skin or areas of pressure may occur.
  • Finally, evaluate the last two characteristics, turgor and mobility, by pinching up a small section of skin on the forearm or sternum, releasing it, and watching for it to immediately return to place.
  • If a lesion is present, inspect and palpate it fully. Remember: Not all lesions are cause for concern, but they should all be examined.

 

First, describe its size (measured in centimeters in all dimensions), shape, color, texture, elevation or depression, and attachment at the base.

 

  • If the lesion has exudates, note their color, odor, amount, and consistency.
  • If there is more than one lesion, describes their configuration as annular (or ring-shaped), arciform (or bow-shaped), grouped, linear, or diffuse.
  • Also record the lesions’ location and distribution, noting whether they appear generalized or localized, affect a specific body region, form a pattern, and are discrete or confluent.
  • Use a light and magnifying glass to determine the lesion’s subtle details, such as color, elevation, and borders.
  • To see if fluid is present in a cyst or mass, transilluminate it in a darkened room. A fluid-filled lesion transilluminates with a red glow; a solid lesion does not.
  • To further identify a lesion, shines a Wood’s lamp on the area in a darkened room. Look for the well-demarcated hypopigmentation of vitiligo, the hyperpigmentation of café au lait spots, and the yellow-green fluorescence that suggests fungal infection. NURS6512 Week 4 Differential Diagnosis for Skin Conditions Assignment

 

To examine the hair, perform the following.

  • To assess the hair, palpate its texture. Scalp hair may be coarse or fine, and curly or straight. It should be shiny, smooth, and resilient.
  • During palpation, also inspect the hair for three characteristics: color, distribution, and quantity.
  • Hair color ranges from very light blond to black to gray.
  • Hair distribution and quantity varies with genetics. Hair commonly appears on the scalp, lower face, neck, nares, ears, chest, axillae, back, shoulders, arms, legs, toes, pubic area, and around the nipples.

To examine the nails, perform the following.

  • Use inspection and palpation to assess the nails. Ask yourself: Are the nails dirty, bitten to the quick, or unkempt? Or are they clean, smooth, and neat? The condition of the hair and nails provides clues to the patient’s self-care, emotions, and social integration.
  • I nspect the nails for five characteristics: color, length, condition, configuration, symmetry, and cleanliness.
  • Although nail shape and opacity can vary greatly, the nail bed color should be pink. Pigment deposits may appear in the nail beds of dark-skinned patients.
  • The nail length and condition should be appropriate—not bitten down to the quick. The nail edges should be smooth and rounded, with no peeling or jagged, broken, or bitten nail edges or cuticles.
  • In configuration, the nail plate should appear smooth and flat or slightly convex. It should have no ridges, grooves, depressions, or pits.
  • The nails should appear bilaterally symmetrical.
  • And the nails should be clean, smooth, and neat.
  • Measure the nail-base angle by placing a ruler across the nail and dorsal surface of the finger and checking the angle formed by the proximal nail fold and nail plate.
  • The nail-base angle should measure 160 degrees.
  • If the nail-base angle is 180 degrees or more, clubbing is present, which suggests a cardiopulmonary or other disorder.
  • Inspect and palpate the proximal and lateral nail folds for redness, swelling, pain, and exudate as well as warts, cysts, and tumors. Pain usually accompanies ingrown nails or infections.
  • Palpate the nail plate for four characteristics: texture, firmness, thickness, and adherence to the nail bed.
  • The texture of the nail plate should be hard and smooth.
  • The nail base should be firm—not boggy.
  • The nail thickness should be uniform. Thickened nails may result from tight-fitting shoes, chronic trauma, or a fungal infection. Nail thinning may accompany a nail disease.
  • The nail should adhere to the nail bed when you gently squeeze the patient’s nail between your thumb and fingerpad.

NURS6512 Week 4 Differential Diagnosis for Skin Conditions Assignment