Differential Diagnosis for Skin Conditions ?? Properly identifying the cause and type of a patients skin condition involves a p
Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions
Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.
In this Lab Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.
To Prepare
- Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.
- Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
- Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
- Consider which of the conditions is most likely to be the correct diagnosis, and why.
- Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.
- Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to guide you as you prepare your SOAP note.
- Download the SOAP Template found in this week’s Learning Resources, and use this template to complete this Lab Assignment.
The Lab Assignment
- Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week's Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
- 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.
Submit your Lab Assignment.
Week 4
Skin Comprehensive SOAP Note Template
Patient Initials: _______ Age: _______ Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Health Maintenance:
Immunization History:
Significant Family History:
Review of Systems:
General:
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Skin/hair/nails:
OBJECTIVE DATA:
Physical Exam:
Vital signs:
General:
HEENT:
Neck:
Chest/Lungs:.
Heart/Peripheral Vascular:
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
Diagnostic results:
ASSESSMENT:
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.
© 2021 Walden University Page 2 of 3
© 20
21
Walden University
Page
1
of
2
Week
4
S
kin
Comprehensive SOAP Note Template
Patient Initials: _______
Age: _______
Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History
(PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/
Social History:
Health
Maintenance:
Immunization History
:
Significant
Family History:
Review of Systems:
General:
HEENT:
Respiratory:
Cardiovascular
/Peripheral Vascular
:
Gastrointestinal:
Genitou
rinary:
Musculoskeletal:
Neurological:
Psychiatric:
Skin
/hair/nails
:
OBJECTIVE DATA:
© 2021 Walden University Page 1 of 2
Week 4
Skin Comprehensive SOAP Note Template
Patient Initials: _______ Age: _______ Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Health Maintenance:
Immunization History:
Significant Family History:
Review of Systems:
General:
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Skin/hair/nails:
OBJECTIVE DATA:
,
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): Eddie Myers is a 58 year old African American male who presents today with a productive cough x 3 days, fever, muscle aches, loss of taste and smell for the last three days. He reported that the “cold feels like it is descending into his chest and he can’t eat much”. The cough is nagging and productive. He brought in a few paper towels with expectorated phlegm – yellow/green in color. He has associated symptoms of dyspnea of exertion and fatigue. His Tmax was reported to be 100.3, last night. He has been taking Tylenol 325mg about every 6 hours and the fever breaks, but returns after the medication wears off. He rated the severity of her symptom discomfort at 8/10.
Medications:
1.) Norvasc 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Advair 500/50 daily
4.) Singulair 10mg daily
5.) Over the counter Tylenol 325mg as needed
6.) Over the counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms
Allergies:
Sulfa drugs – rash
Cipro-headache
Past Medical History (PMH):
1.) Asthma
2.) Hypertension
3.) Osteopenia
4.) Allergic rhinitis
5.) Prostate Cancer
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Prostatectomy 1986
Sexual/Reproductive History:
Heterosexual
Personal/Social History:
He has never smoked
Dipped tobacco for 25 years, no longer dipping
Denied ETOH or illicit drug use.
Immunization History:
Covid Vaccine #1 3/2/2021 #2 4/2/2021 Moderna
Influenza Vaccination 10/3/2020
PNV 9/18/2018
Tdap 8/22/2017
Shingles 3/22/2016
Significant Family History:
One sister – with diabetes, dx at age 65
One brother–with prostate CA, dx at age 62. He has 2 daughters, both in 30’s, healthy, living in nearby neighborhood.
Lifestyle:
He works FT as Xray Tech; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. He is a college grad, owns his home and financially stable.
He has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. He has medical insurance but often asks for drug samples for cost savings. He has a healthy diet and eating pattern. There are resources and community groups in his area at the senior center but he does not attend. He enjoys golf and walking. He has a good support system composed of family and friends.
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; he does wear glasses and his last eye exam was 6 months ago. He reported no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. He does have bilateral small cataracts that are being followed by his ophthalmologist. He has had no recent ear infections, tinnitus, or discharge from the ears. He reported no sense of smell. He has not had any episodes of epistaxis. He does not have a history of nasal polyps or recent sinus infection. He has history of allergic rhinitis that is seasonal. His last dental exam was 1/2020. He denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. He has had no difficulty chewing or swallowing.
Neck: Denies pain, injury, or history of disc disease or compression..
Breasts:. Denies history of lesions, masses or rashes.
Respiratory: + cough and sputum production; denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; he has history of asthma and community acquired pneumonia 2015. Last PPD was 2015. Last CXR – 1 month ago.
CV: denies 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: denies nausea or vomiting, reflux controlled, Denies abd pain, no changes in bowel/bladder pattern. He uses fiber as a daily laxative to prevent constipation.
GU: denies change in her urinary pattern, dysuria, or incontinence. He is heterosexual. No denies history of STD’s or HPV. He is sexually active with his long time girlfriend of 4 years.
MS: he denies arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. denies history of trauma or fractures.
Psych: denies history of anxiety or depression. No sleep disturbance, delusions or mental health history. He denied suicidal/homicidal history.
Neuro: denies syncopal episodes or dizziness, no paresthesia, head aches. denies change in memory or thinking patterns; no twitches or abnormal movements; denies history of gait disturbance or problems with coordination. denies falls or seizure history.
Integument/Heme/Lymph: denies rashes, itching, or bruising. She uses lotion to prevent dry skin. He denies history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties or history of transfusions.
Endocrine: He denies polyuria/polyphagia/polydipsia. Denies fatigue, heat or cold intolerances, shedding of hair, unintentional weight gain or weight loss.
Allergic/Immunologic: He has hx of allergic rhinitis, but no known immune deficiencies. His last HIV test was 2 years ago.
OBJECTIVE DATA
Physical Exam:
Vital signs: B/P 144/98, left arm, sitting, regular cuff; P 90 and regular; T 99.9 Orally; RR 16; non-labored; Wt: 221 lbs; Ht: 5’5; BMI 36.78
General: A&O x3, NAD, appears mildly uncomfortable
HEENT: PERRLA, EOMI, oronasopharynx is clear
Neck: Carotids no bruit, jvd or thyromegally
Chest/Lungs: Lungs pos wheezing, pos for scattered rhonchi
Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial
ABD: nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound
Genital/Rectal: pt declined for this exam
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
Diagnostics/Lab Tests and Results:
CBC – WBC 15,000 with + left shift
SAO2 – 98%
Covid PCR-neg
Influenza- neg
Radiology:
CXR – cardiomegaly with air trapping and increased AP diameter
ECG
Normal sinus rhythm
Spirometry- FEV1 65%
Assessment:
Differential Diagnosis (DDx):
1.) Asthmatic exacerbation, moderate
2.) Pulmonary Embolism
3.) Lung Cancer
Primary Diagnoses:
1.) Asthmatic Exacerbation, moderate
PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]
© 2021 Walden University Page 4 of 4
© 2021 Walden University Page 3 of 4
© 20
21
Walden University
Page
1
of
2
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 C
omplaint
(
CC)
:
Coughing up phlegm
and fever
History of Present Illness (HPI)
:
Eddie
Myers
is a
58
year old
African American
male who presents today with a productive cough x 3
day
s
, fever, muscle aches,
loss of taste and smell for t
he last three days.
H
e reported that the “cold feels like it
is descending into h
is
chest
and he can’t eat much
”. The cough is nagging and
productive.
H
e brought in a few paper towels with expectorated phlegm
–
yellow/
green
in color.
H
e has
associated symp
toms
of dyspnea of exertion and
f
atigue
. H
is
Tmax was reported to be 10
0
.
3
, last night.
H
e has been taking
Tylenol
325
mg about every 6 hours and the fever breaks, but returns after the medication
wears off.
He
rated the severity of her symptom discomfort a
t
8
/10.
Medications:
1.)
Norvasc 10mg daily
2.)
Combivent 2 puffs every 6 hours as needed
3.)
Advair 500/50 daily
4.)
Singulair 10mg daily
5.)
Over the counter
Tylenol 325mg as needed
6.)
Over the counter Benefiber
7.)
Flonase 1 spray each
night
as needed for allergic rhinitis symptoms
Allergies:
Sulfa drugs
–
rash
Cipro
–
headache
Past Medical History
(PMH)
:
1.)
Asthma
2.)
Hypertension
3
.) Osteopenia
4
.) Allergic rhin
itis
5.) Prostate Cancer
Past Surgical History (PSH):
1.)
Cholecystectomy
1994
2.)
Prostatectomy 1986
© 2021 Walden University Page 1 of 2
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): Eddie Myers is a 58 year old African American
male who presents today with a productive cough x 3 days, fever, muscle aches,
loss of taste and smell for the last three days. He reported that the “cold feels like it
is descending into his chest and he can’t eat much”. The cough is nagging and
productive. He brought in a few paper towels with expectorated phlegm –
yellow/green in color. He has associated symptoms of dyspnea of exertion and
fatigue. His Tmax was reported to be 100.3, last night. He has been taking Tylenol
325mg about every 6 hours and the fever breaks, but returns after the medication
wears off. He rated the severity of her symptom discomfort at 8/10.
Medications:
1.) Norvasc 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Advair 500/50 daily
4.) Singulair 10mg daily
5.) Over the counter Tylenol 325mg as needed
6.) Over the counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms
Allergies:
Sulfa drugs – rash
Cipro-headache
Past Medical History (PMH):
1.) Asthma
2.) Hypertension
3.) Osteopenia
4.) Allergic rhinitis
5.) Prostate Cancer
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Prostatectomy 1986
,
Week 4 Lab Assignment: Differential Diagnosis for Skin Conditions
1:
2:
3.
4.
5.
© 2021 Walden University
,
C H A P T E R 2 8
Rashes and skin lesions
Dermatologic problems result from a number of mechanisms, including inflammatory, infectious, immunologic, and environmental (traumatic and exposure induced). At times, the mechanism may be readily identified, such as the infectious bacterial etiology in impetigo. However, some dermatologic lesions may be classified in more than one way. Most insect bites, for example, involve both environmental (the bite) and inflammatory (the response) mechanisms. Awareness of the potential mechanism of any skin disorder is most helpful in identifying the risk a person may have for other illnesses. For example, people with eczema are also frequently at risk for other atopic conditions, notably asthma and allergic rhinitis. Thousands of skin disorders have been described, but only a small number account for the majority of patient visits. Evaluation of rashes and skin lesions depends on a carefully focused history and physical examination. The
provider needs to be familiar with the characteristics of various skin lesions; anatomy, physiology, and pathophysiology of the skin; clinical appearance of the basic lesion; arrangement and distribution of the lesion; and associated pathological conditions. It is also important to know common symptoms associated with specific lesions such as itching or fever. It is necessary to quickly identify life-threatening diseases and those that are highly contagious. Ultimately, competence in dermatologic assessment involves recognition through repetition.
Diagnostic reasoning: Initial focused physical examination
Initial inspection Dermatologic assessment is similar to the assessment of most other body systems in that it depends on patient history and physical assessment. However, sometimes a brief physical assessment preceding the history can assist in the development of the initial differential diagnoses followed by a focused history and further physical examination.
Morphologic criteria Examination involves the classification of the lesion based on a number of morphologic features (examples are listed in Tables 28.1 and 28.2 and illustrated in Figs. 28.1 and 28.2). Evaluation should be systematic. Generally, morphologic features should be analyzed as follows:
• Identify the location of the lesion(s). • Identify the distribution of the lesions as localized, regional, or generalized. • Identify whether the lesion is primary (appearing initially) or secondary (resulting from a change in a primary lesion).
• Identify the shape of the lesion and any arrangement if numerous lesions are present. • Assess the margins (borders). • Assess the pigmentation, including variations. • Palpate to assess texture and consistency. • Measure the size of an individual lesion or estimate the size if lesions are numerous or widespread.
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FIGURE 28.1 Types of skin lesions. Source: (From, Ball JW, Dains JE, Flynn J, et al: Seidel’s guide to physical examination, ed. 8, St. Louis, 2015, Elsevier.)
FIGURE 28.2 Typical distribution of papulosquamous eruptions in children. A, Atopic dermatitis: usually located on the cheeks, creases of elbows, and knees. B, Seborrheic dermatitis: usually located on the scalp, behind the ears, in thigh creases, and in eyebrows. C, Scabies: usually located on the axillae, webs of fingers and toes, and intragluteal area. Source: (From Berkowitz C: Pediatrics: A primary care approach, ed. 2, Philadelphia, 2000, Saunders.)
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Table 28.1
Morphologic Criteria of Rashes and Skin Lesions
PRIMARY LESIONS (DEVELOP INITIALLY IN RESPONSE TO CHANGE IN INTERNAL OR EXTERNAL ENVIRONMENT OF SKIN)
Macule Discrete flat change in color of skin; usually <1.5-cm diameter
Freckle, lentigo, purpura
Patch Discrete flat lesion (large macule); usually >1.5-cm diameter
Pityriasis rosea, melasma, lentigo
Papule Discrete palpable elevation of skin; <1-cm diameter; origin may be epidermal, dermal, or both
Nevi, seborrheic keratosis, dermatofibroma
Nodule Discrete palpable elevation of skin; may evolve from papule; may involve any level of skin from epidermis to subcutis
Nevi, basal cell carcinoma, keratoacanthoma
Plaque Slightly raised lesion, typically with flat surface; >1-cm diameter; scaling frequently present
Psoriasis, mycosis fungoides
Urticaria
NATURE OF DESCRIPTION EXAMPLES
LESION
Wheal Transient pink/red swelling of skin; often displaying central clearing; various shapes and sizes; usually pruritic and lasts <24 hr
Tumor Large papule or nodule; usually >1-cm diameter
Pustule Raised lesion <0.5-cm diameter containing yellow cloudy fluid (usually infected)
Vesicle Raised lesion <0.5-cm diameter containing clear fluid
Bulla Vesicle >0.5-cm diameter
Cyst Semisolid lesion; varies in size from several mm to several cm; may become infected
Basal cell carcinoma, squamous cell carcinoma, malignant melanoma
Folliculitis, acne (closed comedones)
Herpes simplex, herpes zoster, contact (irritant) dermatitis
Bullous pemphigoid, contact (irritant) dermatitis, blisters of second- degree sunburn
Sebaceous cyst
SECONDARY LESIONS (APPEAR AS RESULT OF CHANGES IN PRIMARY LESIONS)
Crust
Scale
Excoriation
Dried exudate that may have been serous, purulent, or hemorrhagic
Thin plates of desquamated stratum corneum that flake off rather easily
Shallow hemorrhagic excavation; linear or punctate; results from scratching
Lichenification Thickening of skin with exaggeration of skin creases; hallmark of chronic eczematous dermatitis
Erosion Partial break in epidermis
Impetigo, herpes zoster (late phase)
Xerosis, ichthyosis, psoriasis
Contact (irritant) dermatitis
Chronic eczema
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