Sample Answer for LAB ASSIGNMENT: DIFFERENTIAL DIAGNOSIS FOR SKIN CONDITIONS NURS 6512 Included After Question
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.
By Day 7 of Week 4
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A Sample Answer For the Assignment: LAB ASSIGNMENT: DIFFERENTIAL DIAGNOSIS FOR SKIN CONDITIONS NURS 6512
Title: LAB ASSIGNMENT: DIFFERENTIAL DIAGNOSIS FOR SKIN CONDITIONS NURS 6512
SUBJECTIVE DATA:
Chief Complaint (CC): Image __: Cellulitis of the leg.
History of Present Illness (HPI): T.N is a 54-year-old Caucasian male patient who presented to the clinic complaining that her left leg is red, tender, and swollen. Additional symptoms include worsening erythema and warmth. The patient reports that these symptoms started about 3 days before the present visit after hitting his leg while washing his car near the garage. He claims that the pain was mild at first but has been worsening ever since. He has tried to use ice blocks which seems to be helpful. He has also been taking Tylenol and Ibuprofen for management of the pain and swelling. He however claims that they only help for a while, but the condition worsens when the drugs wear out of the system.
Medications:
- Ibuprofen 400mg is taken after every 4 to 6 hours for management of the pain.
- Tylenol 650mg PO after every 4 to 6 hours for management of the pain.
- Albuterol Inhaler 2 puffs PRN.
Allergies:
Seasonal allergy reported
No known drug or food allergies reported
Past Medical History (PMH):Diagnosed with asthma at the age of 16 years, which is well controlled with an albuterol inhaler.
Past Surgical History (PSH): Denies any history of hospitalization or undergoing any surgical procedure.
Sexual/Reproductive History:Heterosexual. Married with two kids.
Personal/Social History: He lives with his wife and their younger son in the suburbs. Their older son lives in a nearby town but comes home every weekend. The patient owns a car garage as the family business. He denies smoking tobacco or marijuana. Confirms taking alcohol occasionally when with his friends after work on weekends.
Health Maintenance: Walks to the garage every day, which is about 1 km away from their house, as a form of exercise. Tries very hard to eat a balanced diet, as his wife cooks most of the days. Shows up for routine screening every year.
Immunization History:Up to date. Covid-19 vaccine received on 4th Feb 2021 fist shot and Moderna booster on 5th March 2021. Flu shot receive last on 12/12/2021.
Significant Family History:
Father: with hypertension, and diabetes
Mother: Died from a heart attack.
Younger son: asthmatic
Review of Systems:
General: No weakness, fatigue, nausea, or vomiting. The patient denies any recent changes in body weight.
HEENT:No visual defects. Denies use of corrective glasses. No excessive tearing or redness of the eye. Denies discharge or ear tenderness. No running nose or congestion. Denies sore throat or dental carries.
Neck:No swelling or lump spotted.
Breasts:Asymmetric in size with no lumps or nodules.
Respiratory:No shortness of breath, wheezing, cough, or chest pressure.
Cardiovascular/Peripheral Vascular:No chest pain or palpitations.
Gastrointestinal:No Tenderness, diarrhea, vomiting, abdominal pain or discomfort, bloating, jaundice, constipation, or changes in bowel movement.
Genitourinary:No changes in urine frequency or urgency.
Musculoskeletal:Complaints of pain and swelling of the left lower extremities. Confirms warmth and ecchymosis.Decreased ROM in the leftleg. Full range of movement with no pain on the right leg.
Psychiatric:Denies any history of depression, anxiety, or mood disorders.
Neurological:Denies headache, dizziness, nausea, vomiting, ataxia, paresthesia of syncope.
Skin: No rashes, itching, sores, or dryness.
Hematologic/Lymphatic: No history of anemia, bleeding problems, or prolonged healing of wounds. Denies any signs of enlarged lymph nodes or a history of splenectomy.
Endocrine:No heat or cold intolerance. Denies excessive sweating, polyuria, or polydipsia.
Allergic/Immunologic: Seasonal allergy.
OBJECTIVE DATA:
Physical Exam:
Vital signs:: T- 98.0 °F; Pulse- 66; Rr 16; BP 138/79; Height 5’6’’, Wt. 188 lb. 15
General: The patient appears sickly and walks with difficulties. She is well-groomed and able to respond to questions appropriately. She is very cooperative and pleasant. She, however, appears energetic, with distress only on the left leg.
HEENT:Eyes: Moist conjunctiva, anicteric sclera; no lid lag; PERRLAEars, Nose, Mouth & Throat: Clear oropharynx with moist mucous membranes. No signs of mucosal ulcerations. Full dentition with no signs of bleeding gums. Hard and soft palates were noted with no abnormalities.
Neck:Carotids no bruit, jugular vein distention, or enlarged thyroid gland. Chest/Lungs: Anterior chest wall, bilaterally non-tender to palpation. Bilaterally equal expansions were noted.Bilaterally clear to auscultation. Prolonged expiratory phase. No wheezing, rhonchi, or rales.
Heart/Peripheral Vascular: S1 and S2 noted. Systolic murmur, 2/6. Regular heart rate and rhythm. No gallop or rales were noted.
Abdomen:The patient had bowel sounds present, non-tender, non-distended, obese, soft, no CVA tenderness.
Genital/Rectal:No abnormalities were noted in the genital or rectal area.
Musculoskeletal: Left lower limb edema and erythematous in the arch and along the entire anterior aspect of the left leg up to the mid-shin. No open wounds were noted with drainage. Tenderness in the left lower leg was noted with increased warmth relative to the right leg.
Neurological: Grossly intact. Cranial nerves II through XII.
Skin:Warm and dry, with no rash or lesions.
Diagnostic results:
WBC: 10.1
HGB: 13.2
HCT: 41.2
MCV: 85
BUN: 17
Imaging: X-Ray reveals no deformities (Dains et al., 2019).
ASSESSMENT:
Primary Diagnosis
- Cellulitis of the leg: This disorder is normally diagnosed based on patient history and findings of physical examinations. The patient in the provided case study presented with all the indicating signs and symptoms to qualify for the diagnosis of cellulitis such as worsening tenderness, warmth, redness, swelling, and erythema for 3 days (Edwards et al., 2020). However, a skin sample must be taken to confirm the causative bacteria present.
Differential Diagnosis:
- Lymphedema: It is usually characterized by a disrupted or damaged lymphatic system causing drainage (McPhillips et al., 2021). It mostly affects the arms and legs with presenting symptoms such as pain and swelling just like for the case of the patient in the provided case study. Lymphoscintigraphy tests and Doppler ultrasound are however needed to confirm this diagnosis.
- Osteomyelitis: It is characterized by swelling and tenderness of the bonny tissue (Liu et al., 2020). It is usually caused by an infection. Needle aspiration, bone biopsy, and blood tests are however required to confirm this diagnosis.
- Acute dermatitis: This condition is usually characterized by swelling and redness of the skin with blisters (Rrapi et al., 2021). The patient in the provided case study did not present with blisters disqualifying this diagnosis.
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.
References
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment & clinical diagnosis in primary care.Bottom of Form
-E-Book. Elsevier Health Sciences.
Edwards, G., Freeman, K., Llewelyn, M. J., & Hayward, G. (2020). What diagnostic strategies can help differentiate cellulitis from other causes of red legs in primary care?. BMJ, 368.https://doi.org/10.1136/bmj.m54
Liu, Y., Jain, A., Eng, C., Way, D. H., Lee, K., Bui, P., … & Coz, D. (2020). A deep learning system for differential diagnosis of skin diseases. Nature medicine, 26(6), 900-908.DOI: 10.1038/s41591-020-0842-3
McPhillips, H., Wood, A. F., & Harper-McDonald, B. (2021). Critical thinking and diagnostic reasoning when advanced practitioners assess and treat skin conditions. British Journal of Nursing, 30(22), 1278-1286.https://doi.org/10.12968/bjon.2021.30.22.1278
Rrapi, R., Chand, S., & Kroshinsky, D. (2021). Cellulitis: A Review of Pathogenesis, Diagnosis, and Management. Medical Clinics, 105(4), 723-735.doi:10.1016/j.mcna.2021.04.009
A Sample Answer 2 For the Assignment: LAB ASSIGNMENT: DIFFERENTIAL DIAGNOSIS FOR SKIN CONDITIONS NURS 6512
Title: LAB ASSIGNMENT: DIFFERENTIAL DIAGNOSIS FOR SKIN CONDITIONS NURS 6512
Comprehensive SOAP Template
SUBJECTIVE DATA
Chief Complaint (CC): The patient number 3 complains of a painful rash
History of Present Illness (HPI): Hillary James is a 26 years old African American who presents with an onset of a plague-like rash that has been persisted for three weeks. The patient reports that he first noticed the rash on the knee but later spread to the scalp and elbows. He indicates that the rash is itchy. The patient is disturbed by the condition and indicates that she has been stressed as the issue seems to progress. She has over-the-counter painkiller medication to help relieve the pain. He indicates that the rashes are severe and the associated pain to be 7/10. He suspects that he acquired the skin condition during camping three weeks ago.
Medications: The patient’s current medication includes ibuprofen 400mg PO every 8 hours.
Allergies: The patient has no known drug or food allergy.
Past Medical History (PMH): The patient was recently treated for recurring tonsillitis. He denies having been hospitalized for the past 12 months.
Past Surgical History (PSH): The patient has undergone any surgical procedure in his life.
Sexual/Reproductive History: The patient is married to one wife and they have three children.
Personal/Social History: The patient denies using tobacco or any illicit drug. On the other hand, he enjoys taking alcohol, especially on the weekends. Furthermore, he likes traveling and making new friends.
Immunization History: The patient’s immunization is up to date. His last Tdap was three years ago. Also, he received the flu vaccine a year ago. On the other hand, the patient was not eligible for the pneumonia vaccine at the time he came to the clinic.
Significant Family History: The patient denies a family history of dermatitis or skin rashes.
Lifestyle: The patient works as an electrical technician. He states that he goes to church every Sunday despite his drinking habits. Also, he sleeps late sometimes because of his demanding work. He has an insurance plan and so seeks medical interventions regularly whenever he feels unwell. Furthermore, the patient indicates that he participates in regular dieting and physical exercise. He believes that living an active life reduces the risks of cardiovascular diseases and other conditions.
Review of Systems:
General: The patient is alert and denies experiencing night sweats. He has not gained or lost weight in the past six months. The patient appears energetic; though, slightly disturbed by the skin lesion. Furthermore, the patient has no nail or hair change.
HEENT: There are no changes in the hearing or vision. The patient has a normal visual acuity. The head is intact with no injuries.
Neck: The neck is supple with a full range of motion. There are no signs of lymphadenopathy noted.
Breasts: n/a
Respiratory: No signs of dyspnea or murmurs from the lungs. The lungs are symmetrical. The patient has a normal heart rhythm.
Cardiovascular/Peripheral Vascular: The blood pressure is normal. No signs of peripheral edema.
Gastrointestinal: The patient has a normal bowel movement.
Genitourinary: No pain during micturition. The patient empties their bladder completely
Musculoskeletal: The patient has a full range of motion. No pain in the muscles indicated.
Psychiatric: The patient is calm and cooperative. No signs of depression or hallucination
Neurological:
Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.
Hematologic: Normal C2-C12
Endocrine:
Allergic/Immunologic: NKDA
OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.
Physical Exam:
Vital signs: Ht 5’8’’ Wt=137 lbs, BMI=24.8, T=37.2 degrees Celsius, BP = 125/73mmhg
General: The patient is oriented and well-nourished.
HEENT:
Neck: No JVD
Chest/Lungs: The lung and chest are symmetrical and clear to auscultate
Heart/Peripheral Vascular: Normal heart rate, no cyanosis
Abdomen: Soft, non-tender, and non-distended.
Genital/Rectal:
Musculoskeletal: Full range of motion
Neurological: C2-C12 intact
Skin: the moist, presence of lesions and painful rashes. The pain increases in hot temperatures and on touch.
ASSESSMENT:
The differential diagnosis for the patient includes contact dermatitis, heat rash, and plaque psoriasis. Contact dermatitis is a condition
characterized by causes reddening on the skin and mainly emerges when the skin comes to contact with chemicals (Esser & Martin, 2020). The main symptoms include dry skin and oozing blisters. Also, the patient may their skin turn dark, or swell. In this case, the patient skin is itchy and produces oozing blisters (Yadav, 2021).
The second diagnosis is heat rash, a condition resulting from the blockage of the sweat ducts. The signs and symptoms of heat rash include red bumps on the skin. The patient presents with rashes that are characterized by red bumps and some of them scaly.
The third diagnosis is plaque psoriasis, a condition characterized by raised red patches covered with white build-up (Havnaer & Han, 2019). The kin condition usually shows up in the knees and scalp. The common causes of plaque psoriasis include autoimmune diseases where the body’s immune system fights the healthy cells. Furthermore, injuries to the skin could also trigger the reaction (Rendon & Schäkel, 2019).
REFLECTION:
The clinical experiences provided a good opportunity for learning about the various skin conditions and their presentations. A clear analysis of the skin characteristics in terms of size, component, and the nature of swelling may help in making the right diagnosis. On the other hand, many skin conditions could assume similar characteristics and this makes them prone to misdiagnosis. Furthermore, it was apparent that skin conditions can be traumatizing especially when they are itchy. Patients tend to feel uncomfortable and so the treatment plan should focus on providing relevant psychological counseling to the victims (Wu et al., 2020).
Understanding the anatomical structures of the skin helps in identifying the affected areas and the possible contributing factors. Furthermore, hormonal changes in the body also cause a skin rash; therefore, the hallmark in the diagnosis and treatment process is to identify the causative factors and address them. Not all conditions may require medical intervention as some may only need skincare (Havnaer & Han, 2019). Furthermore, it was evident that having theoretical knowledge is important in the diagnosis process. However, the causes and manifestations of the skin conditions may vary from one individual to the other depending on the socio-cultural and demographic factors.
Besides, the clinical experience allowed me to take a patient’s history and interact with them to understand their underlying conditions and the possible contributing factors. Creating a conducive environment is necessary during the history taking to allow the patients to feel comfortable and share vital information that could help in better management of their conditions. The patient was cooperative and ready to share. He described the onset of the conditions and exposure factors that could be linked with it.
On the other hand, I felt like I did not provide adequate patient education to the client. Patient education is important in equipping the patient with self-care skills and addressing possible social and cultural factors that could be affecting their health condition. Proper hygiene is dietary intake is important. Therefore, in the subsequent clinical practice, I would consider taking good time to offer relevant patient education to improve the treatment outcomes. Other than the nutritional education, I will let the client understand the importance of identifying the skin irritants and avoiding them. Most of the patients tend to seek anti-allergy medications without confirming what illnesses they are having. Skin conditions, like any other disease, may have a poor prognosis if not treated in time.
I agree with the preceptor based on the evidence. The literature analyzed indicates the variations in the characteristics of the various skin conditions. However, there are key features used in the diagnosis that was relevant in this case and guided the differential diagnosis.
References
Esser, P. R., & Martin, S. F. (2020). Extended understanding of pathogenesis and treatment of contact allergy. Der Hautarzt; Zeitschrift fur Dermatologie, Venerologie, und verwandte Gebiete, 71(3), 174-181. https://doi.org/10.1007/s00105-019-04527-9
Havnaer, A., & Han, G. (2019). Autoinflammatory disorders: a review and update on pathogenesis and treatment. American journal of clinical dermatology, 20(4), 539-564.
Rendon, A., & Schäkel, K. (2019). Psoriasis pathogenesis and treatment. International journal of molecular sciences, 20(6), 1475.
Wu, H., Yin, H., Chen, H., Sun, M., Liu, X., Yu, Y., Tang, Y., Long, H., Zhang, B., Zhang, J., Zhou, Y., Li, Y., Zhang, G., Zhang, P., Zhan, Y., Liao, J., Luo, S., Xiao, R., Su, Y., … Lu, Q. (2020). A deep learning, image-based approach for automated diagnosis for inflammatory skin diseases. Annals of Translational Medicine, 8(9), 581-581. https://doi.org/10.21037/atm.2020.04.39
Yadav, A. (2021). A study of diagnosis of skin disease using deep learning techniques. International Journal for Research in Applied Science and Engineering Technology, 9(3), 771-774. https://doi.org/10.22214/ijraset.2021.33310
A Sample Answer 3 For the Assignment: LAB ASSIGNMENT: DIFFERENTIAL DIAGNOSIS FOR SKIN CONDITIONS NURS 6512
Title: LAB ASSIGNMENT: DIFFERENTIAL DIAGNOSIS FOR SKIN CONDITIONS NURS 6512
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.
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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
SUBJECTIVE DATA: “I have indented reddened streaks on my skin that started appearing on the second month when I became pregnant.” “Too many stretch marks on my stomach since being pregnant”
Chief Complaint (CC): Picture #2- I have a concern with the stretch marks on my stomach which first noticed at the end of my first trimester in pregnancy.
History of Present Illness (HPI): Ms Caroline Fisher is a 32 year old female is a gravida 1, para 0 Black American who is pregnant and in her 24 weeks gestational period who came today and complained about the changes she has been noticing on her abdomen that is characterized by streaks of reddened skin which continued to darken as the pregnancy progresses, last menstrual period was 9/21/21. Ms Caroline stated that the stretchmarks are more prominent on the anterior abdominal while few lines run towards the back. Ms Caroline at this time stated that sometimes she feels itchy but denies any pain or any discomfort. Ms Caroline stated that her friends introduced her to an herbal therapy known as cocoa butter which she has been apply but no obvious changes. Ms Caroline is so much concerned about the recent changes to her body and skin and doesn’t feel good about her recent look, Ms Caroline has a believe that she has actually put on weight and that might have worsened the stretchmarks.
Medications:
Patient is on the following medications;
Pregnacare which contains mostly vitamins
400 μg of folic acid prescribed once daily
Iron 600mg Daily
Metformin 500mg twice daily for diabetes
Norvasc 10mg daily for hypertension
Allergies: Allergic to Sulphur medications. No known food allergies.
Past Medical History (PMH): Ms Craoline is a known Type 2 diabetic patient, was last hospitalized in 2020 prior to her recent pregnancy on account of uncontrolled hyperglycemia which was managed and well controlled during the 2 days’ hospitalization before being discharged, patient also has history of borderline hypertension.
Past Surgical History (PSH): Patient denies any surgical history.
Sexual/Reproductive History: Ms. Caroline is Straight and is sexually active. No positive history of sexual abuse, has had 2 partners since she became sexually active. Menarche started at the age of 12 and since then have always had a regular menstrual cycle of 28days.
Personal/Social History: Ms Caroline is an elementary school teacher and lives with the boyfriend in a single family house. Denied history of illegal drug use, drinks alcool occasionally but stopped since she got pregnant.
Health Maintenance: Ms Caroline has been compliant with her regular pregnancy checkup and consults as advised.
Immunization History: Mrs Coroline is upto date with her vaccinations including covid vaccine and the last immunization was the flu shot which she got on 1/3/22
Significant Family History: Father has history of Diabetes which is well controlled with insulin and Mother had hypertension before her death at the age of 60 years in 2021 due to complication of coronavirus.
Review of Systems:
General: Ms Caroline is in a stable condition, no obvious distress noted. She just doesn’t feel good about the recent skin changes since she got pregnancy as that is her first pregnancy.
HEENT: Ms. Caroline denies having any problems with hearing, vision, nasal congestions, nil swelling and no remarkable change on the throat.
Respiratory: Ms Caroline denies any breathing problems
Cardiovascular/Peripheral Vascular: Ms Caroline denies any episodes of irregular heartbeats, denies any heart murmur and not chest pain.
Gastrointestinal: Patient denies any problems with appetite. Confirmed she has regular bowel movements. Patient is positive for constipation occasionally.
Genitourinary: Patient denies any history of urinary tract infection.
Musculoskeletal: Patient is positive mild back pain which she takes regular Tylenol 375mg orally every 8 hrs. when needed.
Neurological: Patient is alert and oriented, no neurological deficit noted. Denies any history of epilepsy or seizures.
Psychiatric: Patient denies any history of mental health illness.
Skin/hair/nails: Ms Caroline is very much concerned about the new stretch
marks that runs through her abdominal wall. Patient does not have any other skin alteration. Patient complained of hair dandruff.
OBJECTIVE DATA:
Physical Exam:
Vital signs: Patients blood pressure measured on the right arm was 144/81, Temperature is 97.7 degree Fahrenheit, Pulse is 72bpm, Respiration is 17c/m, Weight is 179 pounds, height is 5 feet 6 inches and a calculated BMI of 28.9.
General: Ms. Caroline came in alert and oriented to time and place. The vital signs showed that the patient is overweight with a BMI of 28.9 and blood pressure is elevated.
HEENT: On examination of the hair, there were presence of dandruff on the scalp.No inflammation noted on the tonsil and no tenderness noted at the temporomandibular joint. The pupils were equal, round, reactive to light. No discharges noted from ears.
Neck: There was normal range of motion, and no distended juggler vein noted.
Chest/Lungs: The trunk was clear. The intercostal movements were nornmal.no abnormal breath sounds like wheezes. Respiration rate of 18 b/min.
Heart/Peripheral Vascular: On auscultation, the S1 and S2 heart sounds were present and heart rate was within normal limits of 72bpm.
Abdomen: There was positive fetal heart rate of about 128b/m and thee were marked indented streaks on the abdominal wall.
Genital/Rectal: The vagina was free from any signs of infection, nil swelling, discharge or inflammation noted during assessment of the genitalia.
Musculoskeletal: There are no muscle or joint pains noted and there is full range of motion with no limitation.
Neurological: Mrs Caroline is oriented to time, place and person. Patient scored high on assessment of mental status. The mental assessment shows patient has memory intact both recent and past events.
Skin: Patients skin is warm to touch with a temperature of 97.8, nil discoloration noted except the indented stretch marks on the abdominal wall
Diagnostic results:
- There was Lab draw for White blood count which was unremarkable for infection
- On observation of the skin, the streaks and discoloration of the skin were present
- A culture of the skin is important to rule other causes of skin infections.
- Scraping of the nail and skin is key to rule out infections of the skin (Colyar,2015).
ASSESSMENT:
Differential diagnoses
- Linea nigra
- Linear focal elastosis
- Striae from topical steroid abuse, such as in the treatment of psoriasis.
- Cushing’s syndrome.
Primary diagnosis:
After a thorough consideration of other possible causes of this condition, I was able to narrow down the diagnosis based on my assessments and patients present condition to be Striae gravid arum.
Pregnancy as we all know comes with different skin changes as the body adjust to the new normal of accommodating the baby such as the changes that occur within the connective tissues as the skin continues to stretch as the uterus enlarges leads to the stretch marks (Ball, J et.all 2019). This evidence of stretch march shows poor skin elasticity which further puts the patient at risk perineal or vaginal tears due to poor elasticity. When stretch marks becomes evident, it’s as a result of damage to the dermal collagen and further dilation of blood vessels (Dains, Baumann & Scheibel, 2019).
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
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.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Skin, hair, and nails: Student checklist. In Seidel’s guide to physical examination (9th ed.). St. Louis, MO: Elsevier Mosby.
Grading Rubric
| Performance Category | 100% or highest level of performance
100% 16 points |
Very good or high level of performance
88% 14 points |
Acceptable level of performance
81% 13 points |
Inadequate demonstration of expectations
68% 11 points |
Deficient level of performance
56% 9 points
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Failing level
of performance 55% or less 0 points |
| Total Points Possible= 50 | 16 Points | 14 Points | 13 Points | 11 Points | 9 Points | 0 Points |
| Scholarliness
Demonstrates achievement of scholarly inquiry for professional and academic topics. |
Presentation of information was exceptional and included all of the following elements:
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Presentation of information was good, but was superficial in places and included all of the following elements:
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Presentation of information was minimally demonstrated in all of the following elements:
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Presentation of information is unsatisfactory in one of the following elements:
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Presentation of information is unsatisfactory in two of the following elements:
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Presentation of information is unsatisfactory in three or more of the following elements
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| 16 Points | 14 Points | 13 Points | 11 Points | 9 Points | 0 Points | |
| Application of Course Knowledge
Demonstrate the ability to analyze and apply principles, knowledge and information learned in the outside readings and relate them to real-life professional situations |
Presentation of information was exceptional and included all of the following elements:
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Presentation of information was good, but was superficial in places and included all of the following elements:
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Presentation of information was minimally demonstrated in the all of the following elements:
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Presentation of information is unsatisfactory in one of the following elements:
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Presentation of information is unsatisfactory in two of the following elements:
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Presentation of information is unsatisfactory in three of the following elements
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| 10 Points | 9 Points | 6 Points | 0 Points | |||
| Interactive Dialogue
Initial post should be a minimum of 300 words (references do not count toward word count) The peer and instructor responses must be a minimum of 150 words each (references do not count toward word count) Responses are substantive and relate to the topic. |
Demonstrated all of the following:
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Demonstrated 3 of the following:
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Demonstrated 2 of the following:
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Demonstrated 1 or less of the following:
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| 8 Points | 7 Points | 6 Points | 5 Points | 4 Points | 0 Points | |
| Grammar, Syntax, APA
Points deducted for improper grammar, syntax and APA style of writing. The source of information is the APA Manual 6th Edition Error is defined to be a unique APA error. Same type of error is only counted as one error. |
The following was present:
AND
AND
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The following was present:
AND/OR
AND/OR
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The following was present:
AND/OR
AND/OR
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The following was present:
AND/OR
AND/OR
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The following was present:
AND/OR
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The following was present:
AND/OR
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| 0 Points Deducted | 5 Points Lost | |||||
| Participation
Requirements |
Demonstrated the following:
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Failed to demonstrate the following:
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| 0 Points Lost | 5 Points Lost | |||||
| Due Date Requirements | Demonstrated all of the following:
A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT. |
Demonstrates one or less of the following.
A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT. |