Sample Answer for NURS 6512 Assignment 1: Differential Diagnosis for Skin Conditions 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.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
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 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: NURS 6512 Assignment 1: Differential Diagnosis for Skin Conditions
Title: NURS 6512 Assignment 1: Differential Diagnosis for Skin Conditions
Skin Condition Picture # 5
Patient Initials: ___AB_____ Age: _____23__ Gender: ___M____
SUBJECTIVE DATA:
Chief Complaint (CC): Painful rash and joint pain
History of Present Illness (HPI): During the day, AB a 23-year-old lady was presented to the clinic with an onset of painful plague like rashes and pain her joints that started two weeks ago. She added that the rashes started on her knees and later to her elbows and scalps. She further reported the rashes are itchy and sore and complained her joints have painful for the past three weeks. The condition makes her annoyed and worsens as the days go by. More importantly, she added she takes painkillers (Ibuprofen 400mg three times a day) to relieve the pain as well change her laundry detergent with no improvement on her condition.
Onset – Rashes three days
Location – Knee
Duration – Three weeks ago
Character- gradual
Associated symptoms – none
Relieving factors – Painkillers
Treatment – None
Severity – 6/10
Medications:
Takes Ibuprofen 400mg three times a day as prescribed in her local pharmacy.
Multivitamin for women I tablet daily
Allergies: Denies drug or food allergies.
Past Medical History (PMH):
Frequent Tonsillitis
Past Surgical History (PSH):
Tonsillectomy 2006
Caesarian section 2014
Sexual/Reproductive History:
In a monogamous relationship
Menarche 9 years and 8 months
Gravida 1, Parity 0
She experiences regular menstruation
Denies any history of sexually transmitted diseases
She is on Nexplanon contraception for 3 years now
She has her last pap smear in 2018 and results were normal
Social History:
Denies smoking and ETOH intake or substance abuse. She maintains a balanced diet and exercises when she can.
Immunization History:
AB is immunization is up to date according to the World Health Organization. She had a flu vaccine towards the end of last year and her Tdap in 2017 does not fulfill the standards for pneumonia immunization.
Lifestyle:
AB has been working as a receptionist in a local insurance company for the last three months now. AB lives with her elder sister after she had broken up with her boyfriend two years ago. However, she is looking for her own apartment since they have had some differences with her sister. Her sister’s apartment is quite confined after she delivered a baby some months ago as she uses AB’s room as her child’s newborn nursery. As such, she is forced to sleep on the couch with her child. In addition, she helps in nursing her sister and stays late in the night helping with the baby. Luckily, AB has her own health insurance policy and she usually has regular health examination, takes a balanced diet and goes to the gym thrice in a week. More importantly, she agrees the family support is tense due to the newborn and barely have friends to visit her.
Family History
According to AB reports, her father is 47 years of age, and her 43 years old. She is a second born in a family of 4. Both her maternal grandmother mother and paternal grandfather aged 65 and 68 years old respectively have a history of psoriasis and eczema as well as psoriasis arthritis and psoriasis respectively. His father although separated with her mum now, he has a history of multiple allergies and psoriasis. In addition, her mother was diagnosed with breast cancer in 2013 and she is currently in remission. Her two younger brothers were recently diagnosed with an unknown fungal infection.
Review of Systems:
General: Denies having fever, chills, fatigue, night sweats, or significant weight changes
HEENT:
Head/face: No hair loss or head injury, denies headache,
Eyes: Round pupils and reactive to light, Moist mucus Membranes
Ears: Denies having any hearing problems. No tinnitus, no drainage
Nose: No epistasis, nasal congestion, denies having allergies and nasal drainage.
Mouth/Throat/ Neck: Denies sore throat, supple neck, no stiffness, no thyromegaly, no
Lymphadenopathy, no toothache. She had the last dental exam on 20th August 2018.
Musculoskeletal: Positive for diffuse joint pain. No cyanosis, no edema or clubbing. No tenderness on her scapular. Positive dorsalis and radial pulses (2+). Denies any history for gout, arthritis fractures or trauma.
Psychiatric: AB is experiencing social problems, increased stress and sleep problems. However, denies having anxiety depression or suicidal thoughts in the past.
Skin: Polycyclic and pinkish orange-colored plaques approximately 1 cm in size present on her knees, elbows, and scalp, sore and pruritic. No pigment change noticed.
Allergic/Immunologic: Denies any history of drug or food allergies. No known seasonal allergies or immunological condition.
OBJECTIVE DATA:
Physical Exam:
Vital signs: SpO2: 98% tympanic; Ht: 5’7”, Wt: 131lbs, BMI: 23.8, BP 112/68 right arm, sitting, regular adult cuff; Pain severity 6/10; Respiratory Rate- 17, non-labored.
General: AAOx4. Appears neat with a well-kempt hair. Maintains eye contact, fluent in speech and
cooperative.
HEENT: PERRLA, EOMI, normal head traumatic and cephalic, dry oral mucosa, pure oropharynx. Identical pupils, no nasal deviation.
Musculoskeletal: Positive mild swelling on the wrist, knee, and ankle joints bilaterally with pain present. Symmetric muscle development
Skin: Pinkish orange-colored, hoary, polycyclic plaques approximately 1cm in size with discrete borders present on the scalp, elbows, and knees. Sore and a bit painful to palpation. Thick acrylic nails present, limiting nail assessment
Lab Tests and Results:
A complete blood count (CBC) – white blood cells counts (WBC) – 8,500 cells/mcL
Diagnostics:
- Skin biopsy
NURS 6512 Assignment 1 Differential Diagnosis for Skin Conditions
- Positive for psoriasis.
- Negative for fungal infection
ASSESSMENT:
Primary Diagnosis: Psoriasis
Differential Diagnoses:
- Nummular eczema
- Lichen Planus
- Mycosis Fungoides
- Allergic contact dermatitis
- Duhring’s disease
Based on the clinical manifestation presented characterized by rashes and joints paints, it is evident the patient is suffering from psoriasis. Psoriasis is a common condition characterized by dry, raised and red skin lesions covered with silvery scales anywhere in the body such as genitals and on soft tissue. Moreover, plaques or lesions might be itchy and painful (Langley et.al., 2014). Anyone can develop psoriasis. However, family history is one of the most significant risk factors. AB’s family has a history of Psoriasis condition. According to the client, both her maternal grandmother and paternal grandfather suffered from psoriasis and eczema as well as psoriasis arthritis and psoriasis respectively putting her at higher risk of developing the condition. In addition, life stressors can impact significantly on the immune system. As such, high-stress levels increase the risk of psoriasis (Di Meglio & Nestle, 2017). The descriptions of the rashes and their location point out towards the diagnosis of psoriasis. Upon diagnosis of psoriasis, the patient complains of joint pains suggesting she might be suffering from psoriasis arthritis (Ball, Dains, Flynn, Solomon, & Stewart, 2015).
However, despite the lesions/plagues being pinkish orange, all the other differential diagnosis was ruled through skin biopsies. More importantly, Mycosis Fungoides and Lichen Planus are caused by fungi and the skin biopsy results were negative for fungal infection and lichen planus plaques are white (Napolitano et.al.,2016). In addition, the patient does not have any allergies to foods and drugs or immunization disorder hence she could not be diagnosed with allergic contact dermatitis. Furthermore, the patient could not be diagnosed with nummular eczema are allergic related, but the patient does not have any allergic or immunization disorder and the plaques are associated with extensive scratching
References
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.
Napolitano, M., Caso, F., Scarpa, R., Megna, M., Patrì, A., Balato, N., & Costa, L. (2016). Psoriatic arthritis and psoriasis: differential diagnosis. Clinical rheumatology, 35(8), 1893-1901.
Di Meglio, P., & Nestle, F. O. (2017). Immunopathogenesis of Psoriasis. In Clinical and Basic Immunodermatology (pp. 373-395). Springer, Cham.
Langley, R. G., Elewski, B. E., Lebwohl, M., Reich, K., Griffiths, C. E., Papp, K., … & Rivas, E. (2014). Secukinumab in plaque psoriasis—results of two phases 3 trials. New England Journal of Medicine, 371(4), 326-338.
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.
NURS 6512 Assignment 1: Differential Diagnosis for Skin Conditions
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?
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.
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.
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