Review the Skin Conditions document provided in this weeks Learning Resources, and select one condition to closely examine for this Lab Assignment. Consider the abnormal physical

Running header: Lab Assignment: Differential Diagnosis for Skin Conditions 1

Lab Assignment: Differential Diagnosis for Skin Conditions:

Skin Condition Graphic # 4

Master of Science in Nursing, Walden University

NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

March 26, 2022

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Lab Assignment: Differential Diagnosis for Skin Conditions 2

Week 4

Skin Comprehensive SOAP Note Template

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Lab Assignment: Differential Diagnosis for Skin Conditions 3

Patient Initials: JC Age: 65 Gender: Female

SUBJECTIVE DATA:

Chief Complaint (CC): JC is a 65-year-old African American female who presents to

the clinic with complaint of skin condition graphic No. 4.

History of Present Illness (HPI): The patient states that she observed some redness and

swelling in the left lower extremity about two weeks ago. Stated that the affected area

felt hot and tender to touch. The skin of the affected area is red in color and it is noted

with inflammation and swelling. JC stated that she thought it would go away, and that

she had a similar experience last year on the same leg which was treated with antibiotics,

but she was unable to recall the name of the antibiotics. JC stated that the affected area is

developing a sore that appears to be spreading. JC added that she felt pain and the red

area of skin that tends to expand, with swelling, warm and painful, pain rating was 7/10.

JC also endorsed fever, and that she shakes often, that she has chills and was not feeling

well.

Medications:

1. Metformin 1000 mg once daily (with dinner) for Diabetes II.

2. Advil 400 mg every 6 hours as needed for pain.

Allergies: No known allergies

Past Medical History (PMH):

1. Diabetes II,

2. Obesity

Past Surgical History (PSH): None

Sexual/Reproductive History: Heterosexual

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Lab Assignment: Differential Diagnosis for Skin Conditions 4

Personal/Social History:

 Use alcohol occasionally,

 Never smoked

 Denied use of illicit drugs

Health Maintenance:

JC has health insurance from her job, undergoes annual health and physical with

primary care doctor, is compliant with medications. JC states that she was most

recently hospitalized in January 2022 for diabetic crisis, with blood sugar 538.

Stated that she had stopped taking her metformin due to temporary loss of

employment. JC is registered at a gym and tries to limit her intake of

carbohydrates in her diet.

Immunization History:

 Influenza Vaccination in September 2021

 Covid Vaccine declined

 Up to date with all other immunizations

Significant Family History:

 Mother has a history of diabetes type II

 Father has a history of Hypertension,

 Brother has no health problems.

Review of Systems:

General: Pt complains of pain to lower extremity, denies chills, and no decrease in

appetite.

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Lab Assignment: Differential Diagnosis for Skin Conditions 5

HEENT: Denies headache, dizziness, no problems with vision or hearing, no nasal

problems, no difficulty chewing or swallowing.

Respiratory: No respiratory distress, normal effort. Bilateral air entry equally. There is

good respiratory effort with symmetrical thoracic expansion. Lungs are clear to

auscultation.

Cardiovascular/Peripheral Vascular: No issues, denies chest pain or dizziness

Gastrointestinal no change in bowel habits, No nausea, no vomiting, no diarrhea, no

constipation, no melena, no anorexia. Bowel sounds are normoactive. There is no

tenderness. There is no guarding, rebound tenderness, hepatosplenomegaly, or palpable

mass.

Genitourinary: Denies hematuria, nocturia, discharge, dysuria, incontinence, change in

urinary frequency, urinary retention.

Musculoskeletal: Denies muscle pain or weakness.

Neurological: There are no tremors.

Psychiatric: Cooperative, calm. No anxiety, no depression, no suicidal ideation

Skin/hair/nails: There is 2+ left lower extremity and ankle edema with redness,

swelling and pain.

OBJECTIVE DATA:

Physical Exam:

Vital signs: HR 69 BPM RR 22 BP 157/59 BP SpO2 99% HT:170 cm WT:95 kg,

BMI:32. Pain Assessment Primary: Numeric Pain Score: 7/10

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Lab Assignment: Differential Diagnosis for Skin Conditions 6

General: The patient is well groomed, well-developed, well-nourished. In no acute

distress, alert and oriented ×3. Left lower extremity skin appears swollen and red and

painful and warm to the touch.

HEENT: Normocephalic, atraumatic, Normal lids and conjunctiva, anicteric, PERRLA.

Nasal mucosa is without epistaxis or rhinorrhea. Oral mucosa is dry. Neck is supple, no

thyromegaly or thyroid mass.

Chest/Lungs: Normal respiratory effort with symmetrical thoracic expansion. Bilateral

air entry equally. Lungs are clear to auscultation.

Heart/Peripheral Vascular: regular rhythm rate, S1-S2 normal. No gallops or murmurs.

Palpable pulses bilaterally,

Abdomen: Soft and non-tender to palpate, positive bowel sounds in all quadrants.

Genital/Rectal: Declined exam

Musculoskeletal: Strength is 5/5 of the upper and lower extremities bilaterally without

focal deficit.

Neurological: No facial asymmetry, Cranial nerves II through XII grossly intact. There

are no tremors.

Skin: Warm and dry, there is 2+ left lower leg and ankle edema with erythema.

Diagnostic results:

1. Covid PCR: negative

2. EKG: Normal sinus rhythm

3. LLE X-Ray: negative for fractures

4. CBC: WBC 14.6

5. Random Blood Glucose: 285

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Lab Assignment: Differential Diagnosis for Skin Conditions 7

ASSESSMENT:

Differential Diagnosis (DDx):

1. Statis Dermatitis: Stasis dermatitis is a frequent cause of bilateral leg redness, usually

presents with no systemic signs or leukocytosis; commonly occurs bilaterally with

pruritus and red-brown dyspigmentation (VisualDX, 2021). Stasis is a term used to

describe leg swelling seen in conditions of poor circulation and fluid buildup (VisualDX,

2021).

2. Necrotizing fasciitis: Necrotizing fasciitis is a deep and often devastating bacterial

infection that tracks along fascial planes and expands well beyond any outward cutaneous

signs of infection such as erythema (VisualDX, 2021). Necrotizing fasciitis are often

mistaken for cellulitis that is not responding to standard antibiotic therapy (VisualDX,

2021). Necrotizing fasciitis most commonly involves the lower extremities, with the

presence of signs of systemic illness such as fever, lethargy, hypotension, and tachycardia

(VisualDX, 2021).

3. Erysipelas: Erysipelas is a superficial bacterial infection of the skin most often caused

by beta-hemolytic group A streptococci (Streptococcus pyogenes), which involves the

lymphatics of the superficial dermis (VisualDX, 2021). Erysipelas is more commonly

seen on the lower extremities in patients with venous insufficiency and stasis dermatitis

(VisualDX, 2021).

4. Statis Ulcer: A stasis ulcer is a breakdown of the skin (ulcer) caused by fluid build-up in

the skin from poor vein function (venous insufficiency) (VisualDX, 2021). Women are

more often affected by stasis ulcers than men and the risk for acquiring a stasis ulcer

includes overweight (VisualDX, 2021).

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Lab Assignment: Differential Diagnosis for Skin Conditions 8

Primary Diagnoses:

Cellulitis: Cellulitis is a common bacterial infection of the deep dermis and subcutaneous

tissue characterized by erythema, pain, warmth, and swelling; most often caused by the

bacteria Streptococcus or Staphylococcus (VisualDX, 2021). There are no conclusive

tests to determine whether or not you have cellulitis (O’Brien & White, 2021). The Red

Leg RATED tool featured descriptive criteria and photos for identifying cellulitis, as well

as management and follow-up suggestions (O’Brien & White, 2021). Neill et al. (2019)

also suggest a mnemonic for diagnosing Cellulitis which is CELLULITIS: Cellulitis

history, Edema, Local warmth, Lymphangitis, Unilateral, Leukocytosis, Injury, Tender,

Instant onset, and Systemic signs. The first trait has the highest OR and is possibly the

easiest to remember, which is past history of cellulitis (Neill et al., 2019). Cellulitis can

affect any part of the body, but the most common locations are lower legs, arms or hands,

and face (VisualDX, 2021). So based on the referenced researches, given the fact that

there are no conclusive tests to pin point cellulitis, and JC has a past medical history of

the same characteristics, the most likely diagnosis for JC is Cellulitis. Cellulitis involves

a variety of differential diagnoses that result in red, heated, painful swollen limbs

(O’Brien & White, 2021).

PLAN: This section is not required for the assignments in this course (NURS 6512), but will be

required for future courses.

References

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Lab Assignment: Differential Diagnosis for Skin Conditions 9

Neill, B. C., Stoecker, W. V., Hassouneh, R., Rajpara, A., & Aires, D. J. (2019).

CELLULITIS: A mnemonic to increase accuracy of cellulitis diagnosis.

Dermatology Online Journal, 25(1).

O’Brien, G., & White, P. (2021). The Red Legs RATED tool to improve diagnosis of

lower limb cellulitis in the emergency department. British Journal of Nursing (Mark

Allen Publishing), 30(12), S22–S29. https://doi.org/10.12968/bjon.2021.30.12.S22

VisualDx. (2021). Clinical decision support: For professionals. Retrieved March 22, 2022, from

http://www.skinsight.com/professionals

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